Provider Demographics
NPI:1679947543
Name:FANBERG, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FANBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:GINGERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3833 COON RAPIDS BLVD NW STE 120
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2599
Mailing Address - Country:US
Mailing Address - Phone:763-767-3350
Mailing Address - Fax:763-747-0912
Practice Address - Street 1:3833 COON RAPIDS BLVD NW STE 120
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2599
Practice Address - Country:US
Practice Address - Phone:763-767-3350
Practice Address - Fax:763-747-0912
Is Sole Proprietor?:No
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN185221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical