Basic Information
| Provider Information | |||||||||
| NPI: | 1487762837 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROCHELEAU DORHOLT | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD, LP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ROCHELEAU | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | KAY | ||||||||
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| OtherCredential: | PSYD, LP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1900 CENTRACARE CIRCLE SUITE 2475 | ||||||||
| Address2: | CENTRACARE HEALTH PLAZA | ||||||||
| City: | ST. CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202295199 | ||||||||
| FaxNumber: | 3202295109 | ||||||||
| Practice Location | |||||||||
| Address1: | 1406 6TH AVENUE NORTH | ||||||||
| Address2: | ST. CLOUD HOSPITAL | ||||||||
| City: | ST. CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3202295109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2006 | ||||||||
| LastUpdateDate: | 06/29/2012 | ||||||||
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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 | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | LP4779 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.