Basic Information
Provider Information | |||||||||
NPI: | 1013979848 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIMS | ||||||||
FirstName: | JODI | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA LMFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MARCINIAK | ||||||||
OtherFirstName: | JODI | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 14115 JAMES RD STE 305 | ||||||||
Address2: |   | ||||||||
City: | ROGERS | ||||||||
State: | MN | ||||||||
PostalCode: | 553749417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7635758086 | ||||||||
FaxNumber: | 3207740415 | ||||||||
Practice Location | |||||||||
Address1: | 14115 JAMES RD STE 305 | ||||||||
Address2: |   | ||||||||
City: | ROGERS | ||||||||
State: | MN | ||||||||
PostalCode: | 553749417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7635758086 | ||||||||
FaxNumber: | 3207740415 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/05/2006 | ||||||||
LastUpdateDate: | 09/25/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 996 | MN | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 172690 | 01 |   | U CARE | OTHER | 1028944 | 01 | MN | PREFERRED ONE | OTHER | 229R3S1 | 01 | MN | BCBS | OTHER | 1043012 | 01 | MN | PREFERRED ONE | OTHER | HP40189 | 01 |   | HEALTH PARTNERS | OTHER | 6260869 | 01 |   | UBH | OTHER | 914617200 | 05 | MN |   | MEDICAID |