1679612782 NPI number — MS. JENNIFER NELL WHITE MA LP LADC

Table of content: (NPI 1447730056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679612782 NPI number — MS. JENNIFER NELL WHITE MA LP LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITE
Provider First Name:
JENNIFER
Provider Middle Name:
NELL
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA LP LADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHRODE
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
NELL
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679612782
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
FIVE COUNTY MENTAL HEALTH CENTER
Provider Second Line Business Mailing Address:
521 BROADWAY AVENUE NORTH PO BOX 287
Provider Business Mailing Address City Name:
BRAHAM
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-396-3333
Provider Business Mailing Address Fax Number:
320-396-3363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
FIVE COUNTY MENTAL HEALTH CENTER
Provider Second Line Business Practice Location Address:
521 BROADWAY AVENUE NORTH
Provider Business Practice Location Address City Name:
BRAHAM
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-396-3333
Provider Business Practice Location Address Fax Number:
320-396-3363
Provider Enumeration Date:
02/05/2007

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: 103T00000X , with the licence number:  LP2814 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4H134WH . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 16961 . This is a "OPTUM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6212389 . This is a "UBH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1026277 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP24380 . This is a "HEALTHPARTNERS" identifier . This identifiers is of the category "OTHER".