Provider Demographics
NPI:1427110667
Name:FORD, JEFFRY G (MA, LP, LICSW, LMFT)
Entity type:Individual
Prefix:
First Name:JEFFRY
Middle Name:G
Last Name:FORD
Suffix:
Gender:M
Credentials:MA, LP, LICSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 HALLAM AVE S
Mailing Address - Street 2:
Mailing Address - City:MAHTOMEDI
Mailing Address - State:MN
Mailing Address - Zip Code:55115-2217
Mailing Address - Country:US
Mailing Address - Phone:651-483-2522
Mailing Address - Fax:
Practice Address - Street 1:2233 HAMLINE AVE N
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-5009
Practice Address - Country:US
Practice Address - Phone:651-483-2522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0502103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling