Provider Demographics
NPI:1629119912
Name:HANNON, JO ANN FREED (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:JO ANN
Middle Name:FREED
Last Name:HANNON
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4380 COOLIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55424-1020
Mailing Address - Country:US
Mailing Address - Phone:952-926-5648
Mailing Address - Fax:952-926-9175
Practice Address - Street 1:3100 W LAKE ST STE 350
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-5180
Practice Address - Country:US
Practice Address - Phone:952-920-1710
Practice Address - Fax:952-926-9175
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4279103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN322S2HAOtherBLUECROSSBLUESHIELD