Healthcare Provider Details

I. General information

NPI: 1750534434
Provider Name (Legal Business Name): JAY ALAN ORTH LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 13TH ST N
SAINT CLOUD MN
56303-2613
US

IV. Provider business mailing address

1321 13TH ST N
SAINT CLOUD MN
56303-2613
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-5010
  • Fax: 320-203-1855
Mailing address:
  • Phone: 320-252-5010
  • Fax: 320-203-1855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number301931
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: