Provider Demographics
NPI:1255170155
Name:HART, JESSICA L (LADC-S)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:HART
Suffix:
Gender:F
Credentials:LADC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8590 EDINBURGH CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-3723
Mailing Address - Country:US
Mailing Address - Phone:612-462-0540
Mailing Address - Fax:
Practice Address - Street 1:8590 EDINBURGH CENTER DR
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-3723
Practice Address - Country:US
Practice Address - Phone:763-425-5959
Practice Address - Fax:763-425-5929
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304845101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty