Healthcare Provider Details

I. General information

NPI: 1235891052
Provider Name (Legal Business Name): JARED MICHAEL KAINZ LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2021
Last Update Date: 10/11/2021
Certification Date: 10/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 HIGHWAY 12 E STE 2
WILLMAR MN
56201-5811
US

IV. Provider business mailing address

2320 HIGHWAY 12 E STE 2
WILLMAR MN
56201-5811
US

V. Phone/Fax

Practice location:
  • Phone: 320-214-9692
  • Fax: 320-214-9924
Mailing address:
  • Phone: 320-214-9692
  • Fax: 320-214-9924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3039
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3039
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: