Provider Demographics
NPI:1427140508
Name:WEBB, JENNIFER NIELLE (MA, LP)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:NIELLE
Last Name:WEBB
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 98TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5492
Mailing Address - Country:US
Mailing Address - Phone:763-757-8282
Mailing Address - Fax:763-757-8282
Practice Address - Street 1:834 98TH AVE NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5492
Practice Address - Country:US
Practice Address - Phone:763-757-8282
Practice Address - Fax:763-757-8282
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4116103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN380023700#Medicaid
MN125500 GRP # C613OtherOTHER