Provider Demographics
NPI:1295803765
Name:KOZBERG, JILL GURWITZ (M A)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:GURWITZ
Last Name:KOZBERG
Suffix:
Gender:F
Credentials:M A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9901 SAINT JOHNS RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-4640
Mailing Address - Country:US
Mailing Address - Phone:952-936-0926
Mailing Address - Fax:952-936-0927
Practice Address - Street 1:13100 WAYZATA BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1802
Practice Address - Country:US
Practice Address - Phone:952-546-0616
Practice Address - Fax:952-593-1778
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3372103T00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8H790KO 4H557GI LPOtherBLUE CROSS BLUE SHIELD