Healthcare Provider Details

I. General information

NPI: 1083088462
Provider Name (Legal Business Name): CMAJ, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2015
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3820 CLEVELAND AVE N STE 400
ARDEN HILLS MN
55112
US

IV. Provider business mailing address

3820 CLEVELAND AVE N STE 400
ARDEN HILLS MN
55112-3297
US

V. Phone/Fax

Practice location:
  • Phone: 651-389-4406
  • Fax: 651-389-4410
Mailing address:
  • Phone: 651-389-4406
  • Fax: 651-389-4410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number4727
License Number StateMN

VIII. Authorized Official

Name: DR. CHRISTINE ANDERSON JACOB
Title or Position: PRESIDENT/PSYCHOLOGIST
Credential: PH.D, LP
Phone: 651-485-8173