Provider Demographics
NPI:1215534771
Name:HORNIAK, JORDAN GAVIN (BS, LADC)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:GAVIN
Last Name:HORNIAK
Suffix:
Gender:M
Credentials:BS, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2552 KENZIE TER APT 128
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:MN
Mailing Address - Zip Code:55418-4153
Mailing Address - Country:US
Mailing Address - Phone:612-998-7049
Mailing Address - Fax:
Practice Address - Street 1:1404 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1517
Practice Address - Country:US
Practice Address - Phone:612-594-8146
Practice Address - Fax:612-789-8087
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305535101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NOTHINGOtherNOTHING