Provider Demographics
NPI:1700987039
Name:SHIH, JEROME STUART (PHD LP)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:STUART
Last Name:SHIH
Suffix:
Gender:M
Credentials:PHD LP
Other - Prefix:DR
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:SHIH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD LP
Mailing Address - Street 1:306 BUSCH TER
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-5426
Mailing Address - Country:US
Mailing Address - Phone:612-825-9994
Mailing Address - Fax:612-624-0207
Practice Address - Street 1:2431 HENNEPIN AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-2605
Practice Address - Country:US
Practice Address - Phone:612-746-8542
Practice Address - Fax:612-374-3323
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3621103TC1900X, 103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy