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General NPI Number Information
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NPI Number | 1174802979
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Entity Type | Individual
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Provider Name | JEREMEY WAYNE SWANSON LADC
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Gender | Male
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Dates
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Enumeration Date | 08/10/2011
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Last Update Date | 08/10/2011
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Provider Practice Location Address
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Address Line | 7700 HUDSON RD SUITE 600
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City | WOODBURY
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State | MN
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Zip | 55125-1490
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Country | US
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Telephone | 651-731-0037
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Fax | 651-731-6986
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Provider Business Mailing Address
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Address Line | 37 WINDSOR WOOD PATH
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City | HUDSON
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State | WI
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Zip | 54016-7772
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Country | US
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Telephone | 651-755-8406
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Fax | 651-731-6986
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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 | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 302519
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License Number State | MN
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