Provider Demographics
NPI:1013999671
Name:JORENBY, CHARLES HOWARD (MA, LP)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:HOWARD
Last Name:JORENBY
Suffix:
Gender:M
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6885 BOUDIN ST NE STE 200
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-2091
Mailing Address - Country:US
Mailing Address - Phone:952-226-2641
Mailing Address - Fax:952-226-2741
Practice Address - Street 1:6885 BOUDIN ST NE STE 200
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-2091
Practice Address - Country:US
Practice Address - Phone:952-226-2641
Practice Address - Fax:952-226-2741
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3631103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN509108000Medicaid
62-39496OtherUBH ID NUMBER
792566000OtherMAGELLAN ID NUMBER
MNLP3631OtherMINNESOTA BOARD OF PSYCHOLOGY LICENSE NUMBER
2128297OtherCIGNA ID NUMBER
437R8JOOtherBCBS INDIVIDUAL ID NUMBER
437R7LIOtherBCBS GROUP NUMBER