Provider Demographics
NPI:1093249419
Name:HARNACK, JARED (CNP)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:HARNACK
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 S POKEGAMA AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3800
Mailing Address - Country:US
Mailing Address - Phone:218-327-2001
Mailing Address - Fax:
Practice Address - Street 1:516 S POKEGAMA AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3800
Practice Address - Country:US
Practice Address - Phone:218-327-2001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7588363LP0808X
MNR-161518-0163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty