Basic Information
| Provider Information | |||||||||
| NPI: | 1598832933 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JESSER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 13TH AVE W | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DICKINSON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 586014879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012277557 | ||||||||
| FaxNumber: | 7012277575 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 13TH AVE W | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DICKINSON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 586014879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012277557 | ||||||||
| FaxNumber: | 7012277575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 01/05/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 1008 | ND | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 54523 | 05 | ND | MEDICAID |