Basic Information
| Provider Information | |||||||||
| NPI: | 1366699779 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAXSON | ||||||||
| FirstName: | JERRICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | AUD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 3RD AVE SW | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587013880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018575118 | ||||||||
| FaxNumber: | 7018575117 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 3RD AVE SW | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587013880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018575118 | ||||||||
| FaxNumber: | 7018575117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2008 | ||||||||
| LastUpdateDate: | 09/13/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 2008011536 | MO | N | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | 1137 | ND | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.