Provider Demographics
NPI:1770948028
Name:EDWARDS, JANICA SUE (LP)
Entity type:Individual
Prefix:DR
First Name:JANICA
Middle Name:SUE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:JANICA
Other - Middle Name:SUE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:38873 14TH AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MN
Mailing Address - Zip Code:55056-6079
Mailing Address - Country:US
Mailing Address - Phone:651-401-3064
Mailing Address - Fax:651-251-5111
Practice Address - Street 1:300 5TH AVE NE
Practice Address - Street 2:
Practice Address - City:ISANTI
Practice Address - State:MN
Practice Address - Zip Code:55040-2205
Practice Address - Country:US
Practice Address - Phone:763-688-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5973103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical