MEDICARE: DR. JORDAN LYNN HART PH.D., L.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	LP 4313	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	472437200	OTHER	MN	MN MEDICAL ASSISTANCE
2	61-33379	OTHER	MN	MEDICA/UBH
3	991N9HA	OTHER	MN	BCBS INDIVIDUAL PIN
4	108187	OTHER	MN	HEALTHPARTNERS HPFIN

General Provider Information

NPI Number	:	1376524538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORDAN LYNN HART PH.D., L.P.

Provider Business Mailing Address
First Line	:	5353 GAMBLE DR
Second Line	:	SUITE 110
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-1509
Country	:	US
Telephone Number	:	763-432-4071
Fax Number	:	763-432-4073

Provider Business Practice Location Address
First Line	:	5353 GAMBLE DR
Second Line	:	SUITE 110
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-1509
Country	:	US
Telephone Number	:	763-432-4071
Fax Number	:	763-432-4073

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	01/25/2011

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Directions to “ DR. JORDAN LYNN HART PH.D., L.P.” Practice Location

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