Healthcare Provider Details

I. General information

NPI: 1528923182
Provider Name (Legal Business Name): BYRON LEE JEFFERY LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 GOLDEN VALLEY RD
MINNEAPOLIS MN
55411-3139
US

IV. Provider business mailing address

1500 GOLDEN VALLEY RD
MINNEAPOLIS MN
55411-3139
US

V. Phone/Fax

Practice location:
  • Phone: 612-520-9168
  • Fax: 612-520-0047
Mailing address:
  • Phone: 612-520-9168
  • Fax: 612-520-0047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number307056
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: