Provider Demographics
NPI:1851917421
Name:JUDD, JORDAN (LBA)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:JUDD
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9201 OLD CEDAR AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-2401
Mailing Address - Country:US
Mailing Address - Phone:952-854-1800
Mailing Address - Fax:
Practice Address - Street 1:9201 OLD CEDAR AVE S
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-2401
Practice Address - Country:US
Practice Address - Phone:952-854-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLBA0381103K00000X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst