Provider Demographics
NPI:1174802979
Name:SWANSON, JEREMEY WAYNE (LADC)
Entity type:Individual
Prefix:MR
First Name:JEREMEY
Middle Name:WAYNE
Last Name:SWANSON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 WINDSOR WOOD PATH
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-7772
Mailing Address - Country:US
Mailing Address - Phone:651-755-8406
Mailing Address - Fax:651-731-6986
Practice Address - Street 1:7700 HUDSON RD
Practice Address - Street 2:SUITE 600
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1490
Practice Address - Country:US
Practice Address - Phone:651-731-0037
Practice Address - Fax:651-731-6986
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-10
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302519101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor