Healthcare Provider Details

I. General information

NPI: 1851917421
Provider Name (Legal Business Name): JORDAN JUDD LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

758 N PLAZA DR
MENDOTA HEIGHTS MN
55120-1509
US

IV. Provider business mailing address

758 N PLAZA DR
MENDOTA HEIGHTS MN
55120-1509
US

V. Phone/Fax

Practice location:
  • Phone: 651-208-6390
  • Fax:
Mailing address:
  • Phone: 651-280-6390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA0381
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: