MEDICARE: MR. JON JAMES SARGEANT BCBA

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	103K00000X	Behavior Analyst	1-15-5860	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1-15-5860	OTHER	MN	BCBA LICENSE NUMBER

General Provider Information

NPI Number	:	1790369502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JON JAMES SARGEANT BCBA

Provider Business Mailing Address
First Line	:	5617 220TH ST N
Second Line	:
City	:	FOREST LAKE
State	:	MN
Zip	:	55025-9607
Country	:	US
Telephone Number	:	320-241-3296
Fax Number	:

Provider Business Practice Location Address
First Line	:	5617 220TH ST N
Second Line	:
City	:	FOREST LAKE
State	:	MN
Zip	:	55025-9607
Country	:	US
Telephone Number	:	320-241-3296
Fax Number	:

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

Provider Enumeration Date	:	05/07/2021
Last Update Date	:	05/07/2021

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