Provider Demographics
NPI:1902120074
Name:BOERTJE, JULIEANN INGBERG (LMFT,RN)
Entity Type:Individual
Prefix:
First Name:JULIEANN
Middle Name:INGBERG
Last Name:BOERTJE
Suffix:
Gender:F
Credentials:LMFT,RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53032 220TH ST
Mailing Address - Street 2:
Mailing Address - City:WELLS
Mailing Address - State:MN
Mailing Address - Zip Code:56097-6115
Mailing Address - Country:US
Mailing Address - Phone:507-340-5604
Mailing Address - Fax:507-553-3961
Practice Address - Street 1:510 LONG ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4397
Practice Address - Country:US
Practice Address - Phone:507-625-4884
Practice Address - Fax:507-625-6311
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-18
Last Update Date:2010-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1916106H00000X
MNR91359-5163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No163W00000XNursing Service ProvidersRegistered Nurse