Healthcare Provider Details

I. General information

NPI: 1407954753
Provider Name (Legal Business Name): JAN JIRAK MALP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 CLIFTON AVE STE 303
MINNEAPOLIS MN
55403-3376
US

IV. Provider business mailing address

314 CLIFTON AVE STE 303
MINNEAPOLIS MN
55403-3376
US

V. Phone/Fax

Practice location:
  • Phone: 952-985-1097
  • Fax:
Mailing address:
  • Phone: 952-985-1097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP3585
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: