Provider Demographics
NPI:1790369502
Name:SARGEANT, JON JAMES (BCBA)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:JAMES
Last Name:SARGEANT
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5617 220TH ST N
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-9607
Mailing Address - Country:US
Mailing Address - Phone:320-241-3296
Mailing Address - Fax:
Practice Address - Street 1:5617 220TH ST N
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-9607
Practice Address - Country:US
Practice Address - Phone:320-241-3296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1-15-5860103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1-15-5860OtherBCBA LICENSE NUMBER