Healthcare Provider Details

I. General information

NPI: 1184005613
Provider Name (Legal Business Name): JONATHON DAVID SIKORSKI PHD, LP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2015
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 NORTHLAND DR
BLOOMINGTON MN
55431
US

IV. Provider business mailing address

8100 NORTHLAND DR
BLOOMINGTON MN
55431-4800
US

V. Phone/Fax

Practice location:
  • Phone: 952-831-8742
  • Fax: 952-831-1626
Mailing address:
  • Phone: 952-831-8742
  • Fax: 952-831-1626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10061
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4807
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number539
License Number StateNE
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP6449
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: