Provider Demographics
NPI:1265701775
Name:JAYASEKERA, CHAD MICHAEL (MA, LICSW)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:MICHAEL
Last Name:JAYASEKERA
Suffix:
Gender:M
Credentials:MA, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 106TH LN NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-4278
Mailing Address - Country:US
Mailing Address - Phone:651-210-5370
Mailing Address - Fax:
Practice Address - Street 1:1645 106TH LN NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-4278
Practice Address - Country:US
Practice Address - Phone:651-210-5370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2132106H00000X
MN242401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist