Basic Information
| Provider Information | |||||||||
| NPI: | 1871523274 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAGEN | ||||||||
| FirstName: | JOLEEN | ||||||||
| MiddleName: | R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 419 5TH ST NE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584013300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012521050 | ||||||||
| FaxNumber: | 7019523265 | ||||||||
| Practice Location | |||||||||
| Address1: | 419 5TH ST NE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584013300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012521050 | ||||||||
| FaxNumber: | 7019523265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 12/05/2007 | ||||||||
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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 | 133V00000X | 676 | ND | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | P00411343 | 01 | RR MEDICARE | OTHER | 26957 | 01 | BLUE SHIELD | OTHER | HP64722 | 01 | HEALTH PARTNERS | OTHER | 6300416 | 01 | MEDICA | OTHER |