Provider Demographics
NPI:1801076351
Name:MAGNUSON, JILL RENEE (MA, LP)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:RENEE
Last Name:MAGNUSON
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W 78TH ST
Mailing Address - Street 2:SUITE 220C
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-9585
Mailing Address - Country:US
Mailing Address - Phone:612-578-2530
Mailing Address - Fax:952-400-5760
Practice Address - Street 1:600 W 78TH ST
Practice Address - Street 2:SUITE 220C
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-9585
Practice Address - Country:US
Practice Address - Phone:612-578-2530
Practice Address - Fax:952-400-5760
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3686103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist