Healthcare Provider Details

I. General information

NPI: 1720183767
Provider Name (Legal Business Name): JEAN K HARLEY LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7650 CURRELL BLVD SUITE 130
WOODBURY MN
55125-2257
US

IV. Provider business mailing address

1680 BELLOWS ST
SAINT PAUL MN
55118-3805
US

V. Phone/Fax

Practice location:
  • Phone: 651-714-8007
  • Fax:
Mailing address:
  • Phone: 651-647-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3595
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: