Provider Demographics
NPI:1205418340
Name:HARRISON, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HARRISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 HAYWARD AVE N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-7127
Mailing Address - Country:US
Mailing Address - Phone:651-410-7955
Mailing Address - Fax:
Practice Address - Street 1:625 HAYWARD AVE N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-7127
Practice Address - Country:US
Practice Address - Phone:651-410-7955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2310895363LP0808X
MN8119363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health