Basic Information
| Provider Information | |||||||||
| NPI: | 1396052338 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEER | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | RAVEN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3525 MONTEREY DR | ||||||||
| Address2: | PARK NICOLLET CLINIC MELROSE INSTITUTE | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55416 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3525 MONTEREY DRIVE | ||||||||
| Address2: | PARK NICOLLET CLINIC MELROSE INSTITUTE | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529936200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2010 | ||||||||
| LastUpdateDate: | 01/03/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP5283 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.