Basic Information
| Provider Information | |||||||||
| NPI: | 1508878927 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RENWICK | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5877 267TH ST | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550929282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126721518 | ||||||||
| FaxNumber: | 6514644847 | ||||||||
| Practice Location | |||||||||
| Address1: | 5877 267TH ST | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550929282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126721518 | ||||||||
| FaxNumber: | 6514644847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 07/30/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 12222 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 62-23551 | 01 | MN | UBH | OTHER | 1016928 | 01 | MN | PREFERRED ONE | OTHER | 1749701 | 01 | MN | UNITED HEALTHCARE | OTHER | 232216100 | 05 | MN | MEDICAID | 02G98RE | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 20601 | 01 | MN | SIOUX VALLEY HEALTH | OTHER | 62-23551 | 01 | MN | MEDICA | OTHER | 116136 | 01 | MN | UCARE | OTHER | HP37851 | 01 | MN | HEALTH PARTNERS | OTHER |