Healthcare Provider Details

I. General information

NPI: 1629984547
Provider Name (Legal Business Name): NORTHERN LIGHTS PSYCHIATRIC SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1826 COMMERCE DR
NORTH MANKATO MN
56003-1800
US

IV. Provider business mailing address

21298 STATE HIGHWAY 60
EAGLE LAKE MN
56024-4494
US

V. Phone/Fax

Practice location:
  • Phone: 573-590-0267
  • Fax:
Mailing address:
  • Phone: 507-201-9445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JAIMEE ANN KUDRLE
Title or Position: OWNER
Credential: APRN
Phone: 573-590-0267