Provider Demographics
NPI:1063411577
Name:KRISTENSON, JAN DANIELS (LSW)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:DANIELS
Last Name:KRISTENSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:JAN
Other - Middle Name:
Other - Last Name:DANIELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:200 4TH AVE W
Mailing Address - Street 2:GOVERNMENT CENTER RM 300
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-1220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 4TH AVE W
Practice Address - Street 2:GOVERNMENT CENTER RM 300
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-1220
Practice Address - Country:US
Practice Address - Phone:952-496-8504
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5138104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker