Healthcare Provider Details

I. General information

NPI: 1386997179
Provider Name (Legal Business Name): JADE BENDER RAFFERTY PH.D., LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JADE ANDROMEDA BENDER PH.D., LP

II. Dates (important events)

Enumeration Date: 10/18/2012
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 EXCELSIOR BLVD STE 400
ST LOUIS PARK MN
55416-4977
US

IV. Provider business mailing address

4601 EXCELSIOR BLVD STE 400
ST LOUIS PARK MN
55416-4977
US

V. Phone/Fax

Practice location:
  • Phone: 612-767-9860
  • Fax: 612-767-9861
Mailing address:
  • Phone: 612-767-9860
  • Fax: 612-767-9861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: