Healthcare Provider Details

I. General information

NPI: 1013528207
Provider Name (Legal Business Name): STEPHEN SEAN JENKINS PHD, ABPP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W SAINT GERMAIN ST STE 105
SAINT CLOUD MN
56301-4101
US

IV. Provider business mailing address

1411 W SAINT GERMAIN ST STE 105
SAINT CLOUD MN
56301-4180
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-3715
  • Fax:
Mailing address:
  • Phone: 320-253-3715
  • Fax: 320-252-2567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4757
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: