Healthcare Provider Details

I. General information

NPI: 1770696726
Provider Name (Legal Business Name): JACQUELYN K. WIERSMA, PH. D., LP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3931 AUBURN DR
MINNETONKA MN
55305-5196
US

IV. Provider business mailing address

3931 AUBURN DR
MINNETONKA MN
55305-5196
US

V. Phone/Fax

Practice location:
  • Phone: 952-938-9499
  • Fax: 952-938-9499
Mailing address:
  • Phone: 952-938-9499
  • Fax: 952-938-9499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP1583
License Number StateMN

VIII. Authorized Official

Name: DR. JACQUELYN K. WIERSMA
Title or Position: CHIEF MANAGER
Credential: PH. D.
Phone: 952-938-9499