Basic Information
Provider Information | |||||||||
NPI: | 1518067784 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PIERCE | ||||||||
FirstName: | JEAN | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LP, MA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ECK | ||||||||
OtherFirstName: | JEAN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1401 E 1ST ST | ||||||||
Address2: |   | ||||||||
City: | DULUTH | ||||||||
State: | MN | ||||||||
PostalCode: | 558052407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2187284491 | ||||||||
FaxNumber: | 2187284404 | ||||||||
Practice Location | |||||||||
Address1: | 40 11TH ST | ||||||||
Address2: |   | ||||||||
City: | CLOQUET | ||||||||
State: | MN | ||||||||
PostalCode: | 557201817 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2188794559 | ||||||||
FaxNumber: | 2188790282 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2006 | ||||||||
LastUpdateDate: | 09/15/2014 | ||||||||
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 | 103T00000X | LP0957 | MN | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 594751100 | 05 | MN |   | MEDICAID |