Provider Demographics
NPI:1801894209
Name:GRANDE, JODY L FRIESEN (PHD)
Entity type:Individual
Prefix:DR
First Name:JODY
Middle Name:L FRIESEN
Last Name:GRANDE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4205 LANCASTER LN N
Mailing Address - Street 2:SUITE 111
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441
Mailing Address - Country:US
Mailing Address - Phone:763-546-6624
Mailing Address - Fax:763-322-5006
Practice Address - Street 1:4205 LANCASTER LN N
Practice Address - Street 2:SUITE 111
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441
Practice Address - Country:US
Practice Address - Phone:763-546-6624
Practice Address - Fax:763-322-5006
Is Sole Proprietor?:No
Enumeration Date:2005-07-09
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN475522700Medicaid
MN475522700Medicaid