Healthcare Provider Details

I. General information

NPI: 1750838181
Provider Name (Legal Business Name): JONATHAN KODET PHD,LP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 03/27/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 W WAYZATA BLVD # 220
LONG LAKE MN
55356-4413
US

IV. Provider business mailing address

1850 W WAYZATA BLVD # 220
LONG LAKE MN
55356-4413
US

V. Phone/Fax

Practice location:
  • Phone: 612-520-1244
  • Fax:
Mailing address:
  • Phone: 612-520-1244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6186
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6186
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: