Provider Demographics
NPI:1396052338
Name:LEER, JILL RAVEN (PHD, LP)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:RAVEN
Last Name:LEER
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 MONTEREY DR
Mailing Address - Street 2:PARK NICOLLET CLINIC MELROSE INSTITUTE
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3525 MONTEREY DRIVE
Practice Address - Street 2:PARK NICOLLET CLINIC MELROSE INSTITUTE
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416
Practice Address - Country:US
Practice Address - Phone:952-993-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5283103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist