Active NPI
Jody Wallin, LICSW
- Clinical Social Worker
- Maple Grove, MN
National Provider Identifier
1124449392
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- License
- 20641
- Practice address
- 12915 63Rd Ave N
Maple Grove, MN 55369-6001 - Phone
- (952) 826-8465
- NPI assigned
- Dec 13, 2013
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | 20641 | MN | Primary |
Addresses
Primary practice location
12915 63Rd Ave N
Maple Grove, MN 55369-6001
Mailing address
12915 63Rd Ave N
Maple Grove, MN 55369-6001
Phone (952) 826-8465
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 20641 | MN | MD | Internal Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Prairiecare LLC | Clinical | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1386892800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1386892800000",
"number": "1124449392",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "12915 63RD AVE N",
"city": "MAPLE GROVE",
"state": "MN",
"postal_code": "553696001",
"telephone_number": "952-826-8465"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12915 63RD AVE N",
"city": "MAPLE GROVE",
"state": "MN",
"postal_code": "553696001",
"telephone_number": "952-826-8465"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLIN",
"first_name": "JODY",
"credential": "LICSW",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2013-12-13",
"last_updated": "2013-12-13",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "MN",
"license": "20641",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Maple Grove, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 13, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.