Healthcare Provider Details

I. General information

NPI: 1679921340
Provider Name (Legal Business Name): JONATHAN PRESZLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 NORTHLAND DR
BLOOMINGTON MN
55431-4800
US

IV. Provider business mailing address

8170 33RD AVE S # MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC60674058
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number617
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP7072
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: