Healthcare Provider Details

I. General information

NPI: 1295803765
Provider Name (Legal Business Name): JILL GURWITZ KOZBERG M. A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13100 WAYZATA BLVD SUITE 400
MINNETONKA MN
55305-1802
US

IV. Provider business mailing address

9901 SAINT JOHNS RD
MINNETONKA MN
55305-4640
US

V. Phone/Fax

Practice location:
  • Phone: 952-546-0616
  • Fax: 952-593-1778
Mailing address:
  • Phone: 952-936-0926
  • Fax: 952-936-0927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP3372
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP3372
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: