Provider Demographics
NPI:1831664937
Name:JENNIE ENSTAD PSY.D.,L.P. PSYCHOLOGICAL SERVICES LLC
Entity type:Organization
Organization Name:JENNIE ENSTAD PSY.D.,L.P. PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ENSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:763-355-4468
Mailing Address - Street 1:17730 GIBBON ST NW
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:MN
Mailing Address - Zip Code:55303-5510
Mailing Address - Country:US
Mailing Address - Phone:763-355-4468
Mailing Address - Fax:
Practice Address - Street 1:2006 1ST AVE STE 101
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-2255
Practice Address - Country:US
Practice Address - Phone:763-355-4688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN263653100Medicaid