Basic Information
Provider Information | |||||||||
NPI: | 1174566368 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIRCHNER | ||||||||
FirstName: | JODY | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW LICSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MARECK | ||||||||
OtherFirstName: | JODY | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LICSW | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1406 6TH AVENUE NORTH | ||||||||
Address2: | ST CLOUD HOSPITAL | ||||||||
City: | ST CLOUD | ||||||||
State: | MN | ||||||||
PostalCode: | 563031901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202512700 | ||||||||
FaxNumber: | 3206567115 | ||||||||
Practice Location | |||||||||
Address1: | 1406 6TH AVENUE NORTH | ||||||||
Address2: | ST CLOUD HOSPITAL | ||||||||
City: | ST CLOUD | ||||||||
State: | MN | ||||||||
PostalCode: | 563031901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202512700 | ||||||||
FaxNumber: | 3206567115 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2006 | ||||||||
LastUpdateDate: | 03/30/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 10908 | MN | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | 136782C851 | 01 |   | UCARE | OTHER | 6252030 | 01 |   | MEDICA | OTHER | 352192300 | 05 | MN |   | MEDICAID | HP39294 | 01 |   | HEALTH PARTNERS | OTHER | 218727 | 01 |   | OPTUM | OTHER | 68G64K1 | 01 |   | BCBS | OTHER | 922241034347 | 01 |   | PREFERRED ONE | OTHER |