Healthcare Provider Details

I. General information

NPI: 1851548085
Provider Name (Legal Business Name): JAN HAFNER MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9245 QUANTRELLE AVE NE
OTSEGO MN
55330-0168
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW STE 110
NEW BRIGHTON MN
55112-1789
US

V. Phone/Fax

Practice location:
  • Phone: 763-746-9492
  • Fax: 763-746-3685
Mailing address:
  • Phone: 651-379-1718
  • Fax: 651-379-1738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC00924
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC00924
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: