=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417914607
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEAN NAYMARK LICSW, LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2006
-----------------------------------------------------
Last Update Date | 01/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5200 WILLSON RD SUITE 210
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55424-1332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-929-0650
-----------------------------------------------------
Fax | 612-827-7795
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 WILLSON RD SUITE 210
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55424-1332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-929-0650
-----------------------------------------------------
Fax | 612-827-7795
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | LMFT124
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------