=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881986065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JENNIFER BORN, PSY.D., LICENSED PSYCHOLOGIST, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2011
-----------------------------------------------------
Last Update Date | 05/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1595 SELBY AVE SUITE 106
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-600-2011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1595 SELBY AVE SUITE 106
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-600-2011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JENNIFER BORN
-----------------------------------------------------
Credential | PSY.D., LP
-----------------------------------------------------
Telephone | 952-250-1390
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | LP5098
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------