Provider Demographics
NPI:1376911362
Name:KORTGARD, JENNIFER JOY (LICSW)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:JOY
Last Name:KORTGARD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:HANEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2618 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-2159
Mailing Address - Country:US
Mailing Address - Phone:612-201-1893
Mailing Address - Fax:
Practice Address - Street 1:1919 UNIVERSITY AVE W STE 200
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3435
Practice Address - Country:US
Practice Address - Phone:651-266-7999
Practice Address - Fax:651-266-7850
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-08
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21266101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1255805800Medicaid