Healthcare Provider Details

I. General information

NPI: 1083131197
Provider Name (Legal Business Name): JENNIFER EGELAND LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2017
Last Update Date: 08/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 BOONE AVE N
NEW HOPE MN
55428-3636
US

IV. Provider business mailing address

16725 12TH AVE N
PLYMOUTH MN
55447-3001
US

V. Phone/Fax

Practice location:
  • Phone: 763-504-7893
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number22565
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: