Provider Demographics
NPI:1972371821
Name:GEREND, JACOB MICHAEL
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:MICHAEL
Last Name:GEREND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2159 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55118-4803
Mailing Address - Country:US
Mailing Address - Phone:612-889-9707
Mailing Address - Fax:
Practice Address - Street 1:7525 VILLAGE DR STE 130
Practice Address - Street 2:
Practice Address - City:LINO LAKES
Practice Address - State:MN
Practice Address - Zip Code:55014-1305
Practice Address - Country:US
Practice Address - Phone:612-889-9707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty