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General NPI Number Information
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NPI Number | 1134943962
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Entity Type | Individual
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Provider Name | JACOB ROSS TJERNLUND LMFT
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Gender | Male
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Dates
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Enumeration Date | 11/08/2024
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Last Update Date | 11/08/2024
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Provider Practice Location Address
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Address Line | 1619 DAYTON AVE STE 309
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City | SAINT PAUL
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State | MN
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Zip | 55104-6276
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Country | US
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Telephone | 612-746-2975
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Fax |
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Provider Business Mailing Address
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Address Line | 983 CARLTON DR
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City | SHOREVIEW
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State | MN
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Zip | 55126-8130
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Country | US
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Telephone | 651-295-1223
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 4496
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License Number State | MN
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