Healthcare Provider Details

I. General information

NPI: 1083525729
Provider Name (Legal Business Name): JORDAN RUDOLPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 NW 7TH ST
BRAINERD MN
56401-2912
US

IV. Provider business mailing address

611 3RD ST SW
CROSBY MN
56441-1257
US

V. Phone/Fax

Practice location:
  • Phone: 218-855-1115
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number32730
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: