Healthcare Provider Details

I. General information

NPI: 1962815639
Provider Name (Legal Business Name): JENNIFER W KOPLOS PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15265 CARROUSEL WAY STE 100
ROSEMOUNT MN
55068-1760
US

IV. Provider business mailing address

PO BOX 51
VICTORIA MN
55386-0051
US

V. Phone/Fax

Practice location:
  • Phone: 952-443-4600
  • Fax: 952-443-4604
Mailing address:
  • Phone: 952-443-4600
  • Fax: 952-443-4604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3804-57
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5992
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: