Healthcare Provider Details

I. General information

NPI: 1023500113
Provider Name (Legal Business Name): JESSICA BORDENAVE PSYD, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 11/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E 78TH ST STE 100
BLOOMINGTON MN
55420-1402
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW STE 110
NEW BRIGHTON MN
55112-1789
US

V. Phone/Fax

Practice location:
  • Phone: 952-854-5034
  • Fax: 952-854-5363
Mailing address:
  • Phone: 651-628-9566
  • Fax: 651-628-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number3557-57
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6325
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: