Provider Demographics
NPI:1710054325
Name:SCHWARTZ, JAN (MALP LICSW)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:SCHWARTZ
Suffix:
Gender:F
Credentials:MALP LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 EDEN AVE
Mailing Address - Street 2:#109
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436-2337
Mailing Address - Country:US
Mailing Address - Phone:952-926-4613
Mailing Address - Fax:
Practice Address - Street 1:5100 EDEN AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55436-2337
Practice Address - Country:US
Practice Address - Phone:952-926-4613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2192103T00000X
MN8561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8473283938Medicare ID - Type UnspecifiedMEDICARE