Healthcare Provider Details

I. General information

NPI: 1053057497
Provider Name (Legal Business Name): JIBRIL ABDI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 MCANDREWS RD W STE 203
BURNSVILLE MN
55337-4445
US

IV. Provider business mailing address

1500 MCANDREWS RD W STE 203
BURNSVILLE MN
55337-4445
US

V. Phone/Fax

Practice location:
  • Phone: 507-213-6393
  • Fax:
Mailing address:
  • Phone: 507-213-6393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: