Basic Information
| Provider Information | |||||||||
| NPI: | 1689243792 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MURPHY | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | THEIS | ||||||||
| OtherFirstName: | JENNA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2925 CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554071321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122625000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9055 SPRINGBROOK DR NW | ||||||||
| Address2: | |||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554335841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637809155 | ||||||||
| FaxNumber: | 7632361066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2021 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 25805 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.