Provider Demographics
NPI:1205395613
Name:DIRKSE, PAUL JONATHAN
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:JONATHAN
Last Name:DIRKSE
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 1:14949 62ND ST N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6132
Mailing Address - Country:US
Mailing Address - Phone:651-275-7400
Mailing Address - Fax:651-275-7401
Practice Address - Street 1:14949 62ND ST N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6132
Practice Address - Country:US
Practice Address - Phone:651-275-7400
Practice Address - Fax:651-275-7401
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN234591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical