Provider Demographics
NPI:1487820643
Name:FISHER, JON MARK (LICSW)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:MARK
Last Name:FISHER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3490 LEXINGTON AVE N
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-8074
Mailing Address - Country:US
Mailing Address - Phone:651-486-3808
Mailing Address - Fax:651-486-3858
Practice Address - Street 1:3490 LEXINGTON AVE N
Practice Address - Street 2:SUITE 205
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-8074
Practice Address - Country:US
Practice Address - Phone:651-486-3808
Practice Address - Fax:651-486-3858
Is Sole Proprietor?:No
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN162341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical