Provider Demographics
NPI:1639710379
Name:HASSAN, MOHAMED AMIN JAMAL
Entity Type:Individual
Prefix:
First Name:MOHAMED AMIN
Middle Name:JAMAL
Last Name:HASSAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 HUMBOLDT AVE S STE 306
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-1453
Mailing Address - Country:US
Mailing Address - Phone:952-236-7891
Mailing Address - Fax:
Practice Address - Street 1:8200 HUMBOLDT AVE S STE 306
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-1453
Practice Address - Country:US
Practice Address - Phone:952-236-7891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician