Provider Demographics
NPI:1740015643
Name:BARTZEN, JACK DESIRO
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:DESIRO
Last Name:BARTZEN
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 1:3800 AMERICAN BLVD W STE 740
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-4422
Mailing Address - Country:US
Mailing Address - Phone:952-925-8365
Mailing Address - Fax:
Practice Address - Street 1:3800 AMERICAN BLVD W STE 740
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-4422
Practice Address - Country:US
Practice Address - Phone:952-925-8365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician