Healthcare Provider Details

I. General information

NPI: 1578054896
Provider Name (Legal Business Name): JENNICA TOMASSONI PSY.D LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9120 SPRINGBROOK DR NW
COON RAPIDS MN
55433-5845
US

IV. Provider business mailing address

9120 SPRINGBROOK DR NW
COON RAPIDS MN
55433-5845
US

V. Phone/Fax

Practice location:
  • Phone: 612-767-7222
  • Fax:
Mailing address:
  • Phone: 612-767-7222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP6258
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: