Provider Demographics
NPI:1790191252
Name:WIEDEN, JENNA (PHD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:WIEDEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8955 JANE RD N
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-9512
Mailing Address - Country:US
Mailing Address - Phone:651-428-5454
Mailing Address - Fax:
Practice Address - Street 1:333 MAIN ST N STE 110
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-5054
Practice Address - Country:US
Practice Address - Phone:651-425-9297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-05
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TS0200X
MNLP6503103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool