Provider Demographics
NPI:1265724561
Name:TYSON ROBERTS, JAN (PHD)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:TYSON ROBERTS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5353 GAMBLE DR STE 395
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1510
Mailing Address - Country:US
Mailing Address - Phone:612-367-7103
Mailing Address - Fax:952-925-5972
Practice Address - Street 1:5353 GAMBLE DR STE 395
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1510
Practice Address - Country:US
Practice Address - Phone:612-367-7103
Practice Address - Fax:952-925-5972
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-05
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5330103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical