MEDICARE: MS. JAMIE MARIE HERMAN MSW, LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	305157	MN

General Provider Information

NPI Number	:	1316609423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JAMIE MARIE HERMAN MSW, LADC

Provider Business Mailing Address
First Line	:	2104 STEVENS AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-2533
Country	:	US
Telephone Number	:	612-286-1119
Fax Number	:

Provider Business Practice Location Address
First Line	:	2104 STEVENS AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-2533
Country	:	US
Telephone Number	:	612-286-1119
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2021
Last Update Date	:	10/21/2021

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