Provider Demographics
NPI:1740044965
Name:NORTHLIGHT MENTAL HEALTH, PLLC
Entity type:Organization
Organization Name:NORTHLIGHT MENTAL HEALTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-888-0651
Mailing Address - Street 1:202 N CEDAR AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-2306
Mailing Address - Country:US
Mailing Address - Phone:509-768-2249
Mailing Address - Fax:
Practice Address - Street 1:4047 HIGHWAY 61 N STE 202
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-4631
Practice Address - Country:US
Practice Address - Phone:651-237-3102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-08
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty