Provider Demographics
NPI:1275998056
Name:DORN, JAN (LICSW)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:DORN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 WHEELOCK PKWY E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-3939
Mailing Address - Country:US
Mailing Address - Phone:651-487-2728
Mailing Address - Fax:651-487-1512
Practice Address - Street 1:96 WHEELOCK PKWY E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-3939
Practice Address - Country:US
Practice Address - Phone:651-487-2728
Practice Address - Fax:651-487-1512
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN58361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical