Provider Demographics
NPI:1598445967
Name:JEROME, ALIYAH (CNP)
Entity type:Individual
Prefix:
First Name:ALIYAH
Middle Name:
Last Name:JEROME
Suffix:
Gender:
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:5700 BOTTINEAU BLVD STE 210
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55429-3184
Practice Address - Country:US
Practice Address - Phone:763-330-2774
Practice Address - Fax:763-330-2775
Is Sole Proprietor?:No
Enumeration Date:2023-07-20
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN2476407363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health