Active NPI
Jackie Sue Niemand, LIC PSYCHOLOGIST
- Psychologist
- Stillwater, MN
National Provider Identifier
1417958893
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychologist
- License
- LP3518
- Practice address
- 6381 Osgood Ave N Ste 8
Stillwater, MN 55082-6182 - Phone
- (651) 275-9680
- Fax
- (651) 430-9296
- NPI assigned
- Aug 9, 2005
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 5
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Child & Adolescent Psychologist | 103TC2200X | LP3518 | MN | |
| Family Psychologist | 103TF0000X | LP3518 | MN | |
| Psychologist | 103T00000X | LP3518 | MN | Primary |
| Cognitive & Behavioral Psychologist | 103TB0200X | LP3518 | MN | |
| Counseling Psychologist | 103TC1900X | LP3518 | MN |
Addresses
Primary practice location
6381 Osgood Ave N Ste 8
Stillwater, MN 55082-6182
Mailing address
6381 Osgood Ave N Ste 8
Stillwater, MN 55082-6182
Phone (651) 275-9680
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 56B45NI | Other | MN | BLUE CROSS BLUE SHIELD MN |
| 6236625 | Other | MN | UNITED BEHAVIORAL HEALTH |
| 154015700 | Medicaid | MN |
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 |
|---|---|---|---|
| LP3518 | MN | MD | Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1123545600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1612915200000",
"number": "1417958893",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "6381 OSGOOD AVE N STE 8",
"city": "STILLWATER",
"state": "MN",
"postal_code": "550826182",
"telephone_number": "651-275-9680",
"fax_number": "651-430-9296"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "6381 OSGOOD AVE N STE 8",
"city": "STILLWATER",
"state": "MN",
"postal_code": "550826182",
"telephone_number": "651-275-9680",
"fax_number": "651-430-9296"
}
],
"practiceLocations": [],
"basic": {
"last_name": "NIEMAND",
"first_name": "JACKIE",
"middle_name": "SUE",
"credential": "LIC PSYCHOLOGIST",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2005-08-09",
"last_updated": "2021-02-10",
"certification_date": "2021-02-10",
"status": "A"
},
"taxonomies": [
{
"code": "103TC2200X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical Child & Adolescent",
"state": "MN",
"license": "LP3518",
"primary": false
},
{
"code": "103TF0000X",
"taxonomy_group": "",
"desc": "Psychologist, Family",
"state": "MN",
"license": "LP3518",
"primary": false
},
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "MN",
"license": "LP3518",
"primary": true
},
{
"code": "103TB0200X",
"taxonomy_group": "",
"desc": "Psychologist, Cognitive & Behavioral",
"state": "MN",
"license": "LP3518",
"primary": false
},
{
"code": "103TC1900X",
"taxonomy_group": "",
"desc": "Psychologist, Counseling",
"state": "MN",
"license": "LP3518",
"primary": false
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD MN",
"identifier": "56B45NI",
"state": "MN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "UNITED BEHAVIORAL HEALTH",
"identifier": "6236625",
"state": "MN"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "154015700",
"state": "MN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Stillwater, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 10, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.