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General NPI Number Information
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NPI Number | 1073568697
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Entity Type | Individual
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Provider Name | MICHAEL LUTHER JORN PHD
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Gender | Male
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Dates
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Enumeration Date | 05/23/2006
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Last Update Date | 12/04/2014
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Provider Practice Location Address
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Address Line | 4447 N OAKLAND AVE
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City | SHOREWOOD
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State | WI
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Zip | 53211
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Country | US
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Telephone | 414-431-4322
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Fax | 414-431-4323
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Provider Business Mailing Address
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Address Line | 1110 N OLD WORLD 3RD ST STE 410
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City | MILWAUKEE
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State | WI
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Zip | 53203-1121
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Country | US
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Telephone | 414-431-4322
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Fax | 414-431-4323
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1912
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License Number State | WI
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