Basic Information
| Provider Information | |||||||||
| NPI: | 1568013118 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JARA | ||||||||
| FirstName: | KIMBERLY | ||||||||
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| Credential: | M.A., LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5155 E RIVER RD | ||||||||
| Address2: | |||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554211025 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 DELLWOOD ST S | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550081920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7636898700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2019 | ||||||||
| LastUpdateDate: | 01/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 2198 | MN | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | 2198 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.