Jack David Anderson
Individual provider Active NPI Marriage & Family Therapist · Maple Grove, MN
NPI 1023712882 · NPPES record last updated Mar 27, 2023
Key facts
- NPI
- 1023712882
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Marriage & Family Therapist 106H00000X
- Practice address
- 10900 89TH Ave N Ste 3
Maple Grove, MN 55369-4025 - Phone
- (651) 560-0050
- NPI assigned
- Mar 27, 2023
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 3
Medicare Care Compare profile
- Specialty
- Marriage and Family Therapist
- Education
- Other, 2023
- Medicare assignment
- May accept Medicare assignment
Practice addresses (Care Compare)
199 Coon Rapids Blvd NW
Suite 306
Coon Rapids, MN 55433-5831
199 Coon Rapids Blvd NW
Suite 306
Coon Rapids, MN 55433-5861
66 E Flagler St
Miami, FL 33130-1807
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MN
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: No · Power mobility devices: No · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20251231000749 | MN | Practitioner - Marriage and Family Therapist | 5991291841 | Reassigns benefits to 2 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Grow Healthcare Group PA | Marriage & Family Therapist | Current |
Accepting new patients |
| Family Based Therapy Associates | Current |
Accepting new patients | |
| Family Based Therapy Associates | Past |
Accepting new patients |
Locations
237 2nd Ave SW
Ste 117
Cambridge, MN 55008
Phone (763) 200-3411
11549 Lake Ln
Ste 2
Chisago City, MN 55013
Phone (651) 257-2733
199 Coon Rapids Blvd NW
Ste 306
Minneapolis, MN 55433
Phone (763) 780-1520
2355 Highway 36 W
Ste 400
Saint Paul, MN 55113
Phone (612) 460-1597
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Marriage & Family Therapist | 106H00000X | Yes |
Addresses
Primary practice location
10900 89TH Ave N Ste 3
Maple Grove, MN 55369-4025
Mailing address
13060 N 3Rd Ave Apt 1B
Lindstrom, MN 55045-7322
Other providers in Maple Grove, MN
- Amy J. Finn, Marriage and Family Therapy, LLC
- Christian Todd Anderson
- Christine Helen Anderson
- Danielle Nicole Anderson
- Gerald Anderson
- Jennifer Anderson
- Jordan Lillian Anderson
- Joy Nieves Anderson
- Kaitlyn Anderson
- Kellan J Anderson
All providers in Maple Grove, MN · Marriage & Family Therapist in Minnesota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 27, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.