Provider Demographics
NPI:1619024049
Name:NORDGREN, JON C (PHD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:C
Last Name:NORDGREN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:CHRIS
Other - Middle Name:
Other - Last Name:NORDGREN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:4400 W 69TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-8170
Mailing Address - Country:US
Mailing Address - Phone:605-322-4004
Mailing Address - Fax:605-322-4060
Practice Address - Street 1:4400 W 69TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8170
Practice Address - Country:US
Practice Address - Phone:605-322-4004
Practice Address - Fax:605-322-4060
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD340103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN557412900Medicaid
SC6551372Medicaid
SD4995998OtherSD BLUECROSS PROV#
9225136OtherDAKOTACARE
NE10025015700Medicaid
NE10025015700Medicaid