1649611351 NPI number — MS. BROOKE JADE LEJEUNE LCAC

Table of content: MS. BROOKE JADE LEJEUNE LCAC (NPI 1649611351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649611351 NPI number — MS. BROOKE JADE LEJEUNE LCAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEJEUNE
Provider First Name:
BROOKE
Provider Middle Name:
JADE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SELLE
Provider Other First Name:
BROOKE
Provider Other Middle Name:
JADE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649611351
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 E BROADWAY AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BISMARCK
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-222-0386
Provider Business Mailing Address Fax Number:
701-255-4891

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 3RD ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAMESTOWN
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58401-2968
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-253-6300
Provider Business Practice Location Address Fax Number:
701-253-6400
Provider Enumeration Date:
07/10/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  1712 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)