Basic Information
Provider Information | |||||||||
NPI: | 1891876066 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JERSTAD | ||||||||
FirstName: | SARAH | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD LP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | CHILDRENS HEALTH CARE | ||||||||
Address2: | 2910 CENTRE POINTE DRIVE 35 121A | ||||||||
City: | ROSEVILLE | ||||||||
State: | MN | ||||||||
PostalCode: | 55113 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6518552327 | ||||||||
FaxNumber: | 6518552310 | ||||||||
Practice Location | |||||||||
Address1: | CHILDRENS SPECIALTY CLINIC PSYCHOLOGICAL SERVICES STPL | ||||||||
Address2: | 347 NORTH SMITH AVENUE | ||||||||
City: | ST PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 55102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512206720 | ||||||||
FaxNumber: | 6512206707 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/17/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP4676 | MN | X |   | Behavioral Health & Social Service Providers | Psychologist |   | 103TC0700X | LP4676 | MN | X |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | LP4676 | MN | X |   | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TH0100X | LP4676 | MN | X |   | Behavioral Health & Social Service Providers | Psychologist | Health Service |
No ID Information.