Basic Information
| Provider Information | |||||||||
| NPI: | 1770948028 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | JANICA | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | JANICA | ||||||||
| OtherMiddleName: | SUE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 38873 14TH AVE | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | NORTH BRANCH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550566079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514013064 | ||||||||
| FaxNumber: | 6512515111 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 5TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | ISANTI | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550402205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7636889700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2015 | ||||||||
| LastUpdateDate: | 01/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | LP5973 | MN | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | LP5973 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.