Provider Demographics
NPI:1568468312
Name:GOTTLIEB, JEFFREY (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 ARTHUR AVENUE SOUTHEAST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3410
Mailing Address - Country:US
Mailing Address - Phone:651-647-0442
Mailing Address - Fax:
Practice Address - Street 1:2545 CHICAGO AVENUE SOUTH
Practice Address - Street 2:MOB BUILDING, 7TH FLOOR
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404
Practice Address - Country:US
Practice Address - Phone:612-863-4471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1651103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN111748300Medicaid
MN111748300Medicaid