Healthcare Provider Details

I. General information

NPI: 1376524538
Provider Name (Legal Business Name): JORDAN LYNN HART PH.D., L.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5353 GAMBLE DR SUITE 110
ST LOUIS PARK MN
55416-1509
US

IV. Provider business mailing address

5353 GAMBLE DR SUITE 110
ST LOUIS PARK MN
55416-1509
US

V. Phone/Fax

Practice location:
  • Phone: 763-432-4071
  • Fax: 763-432-4073
Mailing address:
  • Phone: 763-432-4071
  • Fax: 763-432-4073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberLP 4313
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: