Provider Demographics
NPI:1386947653
Name:VANDER WEYST, JESSICA ROSE (PSYD, LP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:VANDER WEYST
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1900 CENTRACARE CIRCLE #2475
Mailing Address - Street 2:CENTRACARE HEALTH PLAZA
Mailing Address - City:ST. CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-229-5199
Mailing Address - Fax:320-229-5109
Practice Address - Street 1:1406 6TH AVENUE NORTH
Practice Address - Street 2:ST. CLOUD HOSPITAL
Practice Address - City:ST. CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1901
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5304103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical