Basic Information
| Provider Information | |||||||||
| NPI: | 1265957997 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHIRINOS COSTA | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MERCEDES | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 BURDICK EXPY E STE 101 | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587015006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013356005 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 720 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587013700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013356005 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2017 | ||||||||
| LastUpdateDate: | 02/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.