Provider Demographics
NPI:1336380997
Name:HARTH, JACQUELINE MARIE (LP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:HARTH
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 BLAKE RD N STE 240
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55343-8192
Mailing Address - Country:US
Mailing Address - Phone:952-814-0207
Mailing Address - Fax:952-938-8838
Practice Address - Street 1:415 BLAKE RD N STE 240
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55343-8192
Practice Address - Country:US
Practice Address - Phone:952-814-0207
Practice Address - Fax:952-938-8838
Is Sole Proprietor?:No
Enumeration Date:2009-03-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5040103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral