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General NPI Number Information
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NPI Number | 1306404686
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Entity Type | Individual
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Provider Name | JORDAN PARIS LEUTHOLD MS, LPCC
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Gender | Male
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Dates
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Enumeration Date | 06/03/2019
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Last Update Date | 06/03/2019
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Provider Practice Location Address
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Address Line | 21395 JOHN MILLESS DR STE 400
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City | ROGERS
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State | MN
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Zip | 55374-4407
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Country | US
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Telephone | 763-424-1888
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Fax |
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Provider Business Mailing Address
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Address Line | 13477 73RD PL N
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City | MAPLE GROVE
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State | MN
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Zip | 55311-2831
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Country | US
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Telephone | 952-484-6892
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Fax |
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | CC02131
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License Number State | MN
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