Provider Demographics
NPI:1891167250
Name:ANDERSSON, JARED (MA)
Entity Type:Individual
Prefix:MR
First Name:JARED
Middle Name:
Last Name:ANDERSSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9260 ELLENDALE LN
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-4747
Mailing Address - Country:US
Mailing Address - Phone:612-280-3662
Mailing Address - Fax:
Practice Address - Street 1:14451 HIGHWAY 7 STE 2A
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-3728
Practice Address - Country:US
Practice Address - Phone:612-280-3662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5145103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist