Provider First Line Business Practice Location Address:
640 JACKSON ST
Provider Second Line Business Practice Location Address:
DEPARTMENT OF PSYCHIATRY, MAIL STOP 11302C
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-883-5202
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/10/2012