Provider Demographics
NPI:1396759585
Name:JUNGHANS, STACEY (MA, LP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:JUNGHANS
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MS 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:651-552-2600
Mailing Address - Fax:651-552-2614
Practice Address - Street 1:5625 CENEX DR
Practice Address - Street 2:
Practice Address - City:INVER GROVE HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55077-1724
Practice Address - Country:US
Practice Address - Phone:651-552-2600
Practice Address - Fax:651-552-2614
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN4106103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN285418000Medicaid
MN1022878OtherP1
MN62-62375OtherUBH
MN124596OtherUC
MN20D41JUOtherBCBS
MN30594OtherHP