Provider Demographics
NPI:1679612782
Name:WHITE, JENNIFER NELL (MA LP LADC)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:NELL
Last Name:WHITE
Suffix:
Gender:F
Credentials:MA LP LADC
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:NELL
Other - Last Name:SHRODE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:FIVE COUNTY MENTAL HEALTH CENTER
Mailing Address - Street 2:521 BROADWAY AVENUE NORTH PO BOX 287
Mailing Address - City:BRAHAM
Mailing Address - State:MN
Mailing Address - Zip Code:55006
Mailing Address - Country:US
Mailing Address - Phone:320-396-3333
Mailing Address - Fax:320-396-3363
Practice Address - Street 1:FIVE COUNTY MENTAL HEALTH CENTER
Practice Address - Street 2:521 BROADWAY AVENUE NORTH
Practice Address - City:BRAHAM
Practice Address - State:MN
Practice Address - Zip Code:55006
Practice Address - Country:US
Practice Address - Phone:320-396-3333
Practice Address - Fax:320-396-3363
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2814103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4H134WHOtherBCBS
16961OtherOPTUM
6212389OtherUBH
1026277OtherPREFERRED ONE
HP24380OtherHEALTHPARTNERS