Basic Information
Provider Information | |||||||||
NPI: | 1750303244 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JESSEN | ||||||||
FirstName: | MANDY | ||||||||
MiddleName: | SUMMER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JOHNSON | ||||||||
OtherFirstName: | MANDY | ||||||||
OtherMiddleName: | SUMMER | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 820 4TH ST N | ||||||||
Address2: |   | ||||||||
City: | FARGO | ||||||||
State: | ND | ||||||||
PostalCode: | 581220001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7012346161 | ||||||||
FaxNumber: | 7012343861 | ||||||||
Practice Location | |||||||||
Address1: | 737 BROADWAY N | ||||||||
Address2: |   | ||||||||
City: | FARGO | ||||||||
State: | ND | ||||||||
PostalCode: | 581220001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7012344811 | ||||||||
FaxNumber: | 7012346979 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2006 | ||||||||
LastUpdateDate: | 02/13/2019 | ||||||||
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 | 363L00000X | R28421 | ND | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.