Provider Demographics
NPI:1427329143
Name:BOSTROM, JARED BRENT (LMFT, LADC, CPRP)
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:BRENT
Last Name:BOSTROM
Suffix:
Gender:M
Credentials:LMFT, LADC, CPRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E 80TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-1426
Mailing Address - Country:US
Mailing Address - Phone:952-956-3101
Mailing Address - Fax:952-564-3031
Practice Address - Street 1:1100 E 80TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-1426
Practice Address - Country:US
Practice Address - Phone:952-956-3101
Practice Address - Fax:952-564-3031
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4866770101Y00000X, 101YM0800X
MN303234101YA0400X
MN2913106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist