Provider Demographics
NPI:1376524538
Name:HART, JORDAN LYNN (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:LYNN
Last Name:HART
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5353 GAMBLE DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1509
Mailing Address - Country:US
Mailing Address - Phone:763-432-4071
Mailing Address - Fax:763-432-4073
Practice Address - Street 1:5353 GAMBLE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1509
Practice Address - Country:US
Practice Address - Phone:763-432-4071
Practice Address - Fax:763-432-4073
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 4313103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN472437200OtherMN MEDICAL ASSISTANCE
MN61-33379OtherMEDICA/UBH
MN991N9HAOtherBCBS INDIVIDUAL PIN
MN108187OtherHEALTHPARTNERS HPFIN