MEDICARE: MS. JODY MORK MA

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	106H00000X	Marriage & Family Therapist	2009	MN

General Provider Information

NPI Number	:	1790105880
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JODY MORK MA

Provider Business Mailing Address
First Line	:	425 COON RAPIDS BLVD NW STE 200
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55433-2753
Country	:	US
Telephone Number	:	763-360-8023
Fax Number	:	763-784-3647

Provider Business Practice Location Address
First Line	:	425 COON RAPIDS BLVD NW STE 200
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55433-2753
Country	:	US
Telephone Number	:	763-360-8023
Fax Number	:	763-784-3647

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

Provider Enumeration Date	:	04/16/2014
Last Update Date	:	04/16/2014

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