Provider Demographics
NPI:1962815639
Name:KOPLOS, JENNIFER W (PSYD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:W
Last Name:KOPLOS
Suffix:
Gender:F
Credentials:PSYD
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 51
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:MN
Mailing Address - Zip Code:55386-0051
Mailing Address - Country:US
Mailing Address - Phone:952-443-4600
Mailing Address - Fax:952-443-4604
Practice Address - Street 1:15265 CARROUSEL WAY STE 100
Practice Address - Street 2:
Practice Address - City:ROSEMOUNT
Practice Address - State:MN
Practice Address - Zip Code:55068-1760
Practice Address - Country:US
Practice Address - Phone:952-443-4600
Practice Address - Fax:952-443-4604
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3804-57103TC0700X
MN5992103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical