Provider Demographics
NPI:1306404686
Name:LEUTHOLD, JORDAN PARIS (MS, LPCC)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:PARIS
Last Name:LEUTHOLD
Suffix:
Gender:M
Credentials:MS, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13477 73RD PL N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-2831
Mailing Address - Country:US
Mailing Address - Phone:952-484-6892
Mailing Address - Fax:
Practice Address - Street 1:21395 JOHN MILLESS DR STE 400
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-4407
Practice Address - Country:US
Practice Address - Phone:763-424-1888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC02131101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional