Healthcare Provider Details

I. General information

NPI: 1174288302
Provider Name (Legal Business Name): JENNA DANIELE GUNNERSON PSYD, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2021
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 XERXES AVE S STE 110
BLOOMINGTON MN
55431-1200
US

IV. Provider business mailing address

4716 KINGSDALE DR
BLOOMINGTON MN
55437-1829
US

V. Phone/Fax

Practice location:
  • Phone: 763-607-7817
  • Fax:
Mailing address:
  • Phone: 612-360-5959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberLP6745
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: