Healthcare Provider Details

I. General information

NPI: 1053995597
Provider Name (Legal Business Name): JENNA HASSANEIN RAAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 XERXES AVE S STE 116
BLOOMINGTON MN
55431-1200
US

IV. Provider business mailing address

6881 CHANNEL RD NE
FRIDLEY MN
55432-4619
US

V. Phone/Fax

Practice location:
  • Phone: 612-201-2468
  • Fax:
Mailing address:
  • Phone: 612-434-9679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA0975
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: