Healthcare Provider Details

I. General information

NPI: 1427329143
Provider Name (Legal Business Name): JARED BRENT BOSTROM LMFT, LADC, CPRP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2012
Last Update Date: 11/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E 80TH ST
BLOOMINGTON MN
55420-1426
US

IV. Provider business mailing address

1100 E 80TH ST STE 100
BLOOMINGTON MN
55420-1426
US

V. Phone/Fax

Practice location:
  • Phone: 952-956-3101
  • Fax: 952-564-3031
Mailing address:
  • Phone: 952-956-3101
  • Fax: 952-564-3031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number4866770
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number303234
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2913
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4866770
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: