Healthcare Provider Details

I. General information

NPI: 1548609019
Provider Name (Legal Business Name): JANE CATHERINE HANSEN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1966 WALNUT ST
LAUDERDALE MN
55113-5136
US

IV. Provider business mailing address

1966 WALNUT ST
LAUDERDALE MN
55113-5136
US

V. Phone/Fax

Practice location:
  • Phone: 612-418-0694
  • Fax:
Mailing address:
  • Phone: 612-418-0694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number20689
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: