Provider Demographics
NPI:1245092279
Name:JAHN, MARY NAOMI (LADC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:NAOMI
Last Name:JAHN
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 E HIGHWAY 7
Mailing Address - Street 2:
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:56265-1705
Mailing Address - Country:US
Mailing Address - Phone:320-269-6581
Mailing Address - Fax:855-562-7905
Practice Address - Street 1:1234 E HIGHWAY 7
Practice Address - Street 2:
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265-1705
Practice Address - Country:US
Practice Address - Phone:320-269-6581
Practice Address - Fax:855-562-7905
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303665101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)