Provider Demographics
NPI:1588779292
Name:HOISTAD, JONATHAN C (PHD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:C
Last Name:HOISTAD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 UNIVERSITY AVE W STE 155
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-2880
Mailing Address - Country:US
Mailing Address - Phone:612-800-6500
Mailing Address - Fax:612-800-6501
Practice Address - Street 1:1821 UNIVERSITY AVE W STE 155
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-2880
Practice Address - Country:US
Practice Address - Phone:612-800-6500
Practice Address - Fax:612-800-6501
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1535-057103T00000X
MN716103T00000X
MNLP1788103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39024800Medicaid