Provider Demographics
NPI:1548151095
Name:JAMA, LIBAN
Entity type:Individual
Prefix:
First Name:LIBAN
Middle Name:
Last Name:JAMA
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4312 SHADY OAK RD S APT 217
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-6932
Mailing Address - Country:US
Mailing Address - Phone:612-978-8046
Mailing Address - Fax:
Practice Address - Street 1:4312 SHADY OAK RD S APT 217
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-6932
Practice Address - Country:US
Practice Address - Phone:612-978-8046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health