Provider Demographics
NPI:1073568697
Name:JORN, MICHAEL LUTHER (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LUTHER
Last Name:JORN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 N OLD WORLD 3RD ST STE 410
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-1121
Mailing Address - Country:US
Mailing Address - Phone:414-431-4322
Mailing Address - Fax:414-431-4323
Practice Address - Street 1:4447 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211
Practice Address - Country:US
Practice Address - Phone:414-431-4322
Practice Address - Fax:414-431-4323
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1912103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S21313Medicare UPIN
000001208Medicare ID - Type Unspecified