Provider Demographics
NPI:1750190492
Name:PEDERSEN, JEFFREY CARL (LADC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:CARL
Last Name:PEDERSEN
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 1:9896 57TH ST N
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-9588
Mailing Address - Country:US
Mailing Address - Phone:651-285-2865
Mailing Address - Fax:
Practice Address - Street 1:9896 57TH ST N
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-9588
Practice Address - Country:US
Practice Address - Phone:651-285-2865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305311101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)