Provider Demographics
NPI:1538625256
Name:D'AMBROSIO, JAN MARIE (MA, LMFT)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:MARIE
Last Name:D'AMBROSIO
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:JAN
Other - Middle Name:D'AMBROSIO
Other - Last Name:HINTZE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:475 W EAGLE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-5528
Mailing Address - Country:US
Mailing Address - Phone:612-351-2283
Mailing Address - Fax:
Practice Address - Street 1:11141 ZEALAND AVE N
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-3595
Practice Address - Country:US
Practice Address - Phone:763-951-3091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MN3856106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist