Provider Demographics
NPI:1962469171
Name:KEARNEY, JEFFREY (PHD, LP)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:KEARNEY
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-0230
Mailing Address - Country:US
Mailing Address - Phone:320-258-3833
Mailing Address - Fax:320-253-5741
Practice Address - Street 1:3812 8TH ST N STE 200
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1421
Practice Address - Country:US
Practice Address - Phone:320-258-3833
Practice Address - Fax:320-253-5741
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3727103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2028601OtherBLUE CROSS
MN88805OtherGROUP HEALTH
MN1015046OtherPREFERRED ONE
MN167303OtherUCARE
MN268J3KEOtherBLUES
MN6174715OtherMEDICA
MN902716500Medicaid
MN167303OtherUCARE