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NPI Code Detail

MEDICARE: JON COLOMBO

MEDICARE: JON COLOMBO
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
1103TC0700XClinical PsychologistLP 5165MN

General Provider Information

NPI Number : 1609865674
Entity Type Code : Individual
Provider Name (Legal Business Name) : JON COLOMBO
Provider Business Mailing Address
First Line : 8669 EAGLE POINT BLVD
Second Line :
City : LAKE ELMO
State : MN
Zip : 55042-8628
Country : US
Telephone Number : 651-379-0444
Fax Number :
Provider Business Practice Location Address
First Line : 8669 EAGLE POINT BLVD
Second Line :
City : LAKE ELMO
State : MN
Zip : 55042-8628
Country : US
Telephone Number : 651-379-0444
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/20/2005
Last Update Date : 12/15/2011

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Directions to “ JON COLOMBO ” Practice Location

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