Provider Demographics
NPI:1760544423
Name:KURTZ, JEANNE MARIE (PHD, LP)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:MARIE
Last Name:KURTZ
Suffix:
Gender:F
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 1:7115 FORTHUN ROAD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425
Mailing Address - Country:US
Mailing Address - Phone:218-454-0090
Mailing Address - Fax:218-454-0091
Practice Address - Street 1:7115 FORTHUN ROAD
Practice Address - Street 2:SUITE 105
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425
Practice Address - Country:US
Practice Address - Phone:218-454-0090
Practice Address - Fax:218-454-0091
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2689103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4209552Medicaid
MNLP2689OtherLICENSED PSYCHOLOGIST
MN4209552Medicaid