Provider Demographics
NPI:1407954753
Name:JIRAK, JAN (MALP)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:JIRAK
Suffix:
Gender:F
Credentials:MALP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 CLIFTON AVE STE 303
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-3376
Mailing Address - Country:US
Mailing Address - Phone:952-985-1097
Mailing Address - Fax:
Practice Address - Street 1:314 CLIFTON AVE STE 303
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-3376
Practice Address - Country:US
Practice Address - Phone:952-985-1097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3585103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN154319900Medicaid