Healthcare Provider Details

I. General information

NPI: 1679612782
Provider Name (Legal Business Name): JENNIFER NELL WHITE MA LP LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER NELL SHRODE MA

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FIVE COUNTY MENTAL HEALTH CENTER 521 BROADWAY AVENUE NORTH
BRAHAM MN
55006
US

IV. Provider business mailing address

FIVE COUNTY MENTAL HEALTH CENTER 521 BROADWAY AVENUE NORTH PO BOX 287
BRAHAM MN
55006
US

V. Phone/Fax

Practice location:
  • Phone: 320-396-3333
  • Fax: 320-396-3363
Mailing address:
  • Phone: 320-396-3333
  • Fax: 320-396-3363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP2814
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: