Provider Demographics
NPI:1356847701
Name:BRUNSGAARD, JEFFREY ERIC JOHN
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ERIC JOHN
Last Name:BRUNSGAARD
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 1:9120 SPRINGBROOK DR NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5845
Mailing Address - Country:US
Mailing Address - Phone:763-233-7264
Mailing Address - Fax:
Practice Address - Street 1:7401 METRO BLVD STE 250
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-3062
Practice Address - Country:US
Practice Address - Phone:612-447-0647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01755101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional