MEDICARE: VERNON CLAUDE JESSE PHD LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	LP0884	MN

General Provider Information

NPI Number	:	1225134240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VERNON CLAUDE JESSE PHD LP

Provider Business Mailing Address
First Line	:	2497 7TH AVE E
Second Line	:	SUITE 101
City	:	NORTH ST. PAUL
State	:	MN
Zip	:	55109-2496
Country	:	US
Telephone Number	:	651-769-6437
Fax Number	:	651-769-6426

Provider Business Practice Location Address
First Line	:	1185 TOWN CENTRE DR
Second Line	:	SUITE 225
City	:	EAGAN
State	:	MN
Zip	:	55123-1186
Country	:	US
Telephone Number	:	651-769-6200
Fax Number	:	651-769-6249

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	07/08/2007

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