Healthcare Provider Details

I. General information

NPI: 1518893536
Provider Name (Legal Business Name): JEFF A WIENS HEINSOHN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 OSBORNE RD NE
FRIDLEY MN
55432-2718
US

IV. Provider business mailing address

520 OSBORNE RD NE
FRIDLEY MN
55432-2718
US

V. Phone/Fax

Practice location:
  • Phone: 763-236-4510
  • Fax: 763-236-7370
Mailing address:
  • Phone: 763-236-4510
  • Fax: 763-236-7370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number302212
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: