Provider Demographics
NPI:1376588798
Name:KOLL, JON M (MS CP)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:M
Last Name:KOLL
Suffix:
Gender:M
Credentials:MS CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1321 13TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2614
Mailing Address - Country:US
Mailing Address - Phone:320-252-5010
Mailing Address - Fax:320-203-1855
Practice Address - Street 1:407 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8815
Practice Address - Country:US
Practice Address - Phone:763-295-4001
Practice Address - Fax:763-295-5086
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2938103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HP27746OtherHEALTH PARTNERS
208GOKOOtherBLUE CROSS BLUE SHIELD
922241007838OtherPREFERRED ONE
6250886OtherMEDICA