Provider Demographics
NPI:1992114326
Name:GUILLAUME MARSHALL, JEANETTE LORRAINE (PHD)
Entity type:Individual
Prefix:DR
First Name:JEANETTE
Middle Name:LORRAINE
Last Name:GUILLAUME MARSHALL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 HIGHWAY 96 W STE 280
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-3217
Mailing Address - Country:US
Mailing Address - Phone:651-200-3788
Mailing Address - Fax:
Practice Address - Street 1:470 HIGHWAY 96 W STE 280
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-3217
Practice Address - Country:US
Practice Address - Phone:651-200-3788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNGL0029103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical