Provider Demographics
NPI:1629005277
Name:HARRIS, JANE (MA LP)
Entity Type:Individual
Prefix:MRS
First Name:JANE
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15840 ELODIE LN
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-4545
Mailing Address - Country:US
Mailing Address - Phone:612-839-7975
Mailing Address - Fax:
Practice Address - Street 1:3131 FERNBROOK LN N
Practice Address - Street 2:SUITE 102
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5321
Practice Address - Country:US
Practice Address - Phone:612-839-7975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3146103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN664817700Medicaid