Healthcare Provider Details

I. General information

NPI: 1427110667
Provider Name (Legal Business Name): JEFFRY G. FORD MA, LP, LICSW, LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 12/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 HAMLINE AVE N
ROSEVILLE MN
55113-5009
US

IV. Provider business mailing address

410 HALLAM AVE S
MAHTOMEDI MN
55115-2217
US

V. Phone/Fax

Practice location:
  • Phone: 651-483-2522
  • Fax:
Mailing address:
  • Phone: 651-483-2522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP0502
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: