Provider Demographics
NPI:1750838181
Name:KODET, JONATHAN (PHD,LP)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:KODET
Suffix:
Gender:M
Credentials:PHD,LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 W WAYZATA BLVD # 220
Mailing Address - Street 2:
Mailing Address - City:LONG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55356-4413
Mailing Address - Country:US
Mailing Address - Phone:612-520-1244
Mailing Address - Fax:
Practice Address - Street 1:1850 W WAYZATA BLVD # 220
Practice Address - Street 2:
Practice Address - City:LONG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55356-4413
Practice Address - Country:US
Practice Address - Phone:612-520-1244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6186103TC1900X, 103TC0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN103TC0700XMedicaid