1851784987 NPI number — JEANNE MARIE HETTICH FARNSWORTH LPCC

Table of content: JEANNE MARIE HETTICH FARNSWORTH LPCC (NPI 1851784987)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851784987 NPI number — JEANNE MARIE HETTICH FARNSWORTH LPCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FARNSWORTH
Provider First Name:
JEANNE
Provider Middle Name:
MARIE HETTICH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HETTICH
Provider Other First Name:
JEANNE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1851784987
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 SHADY ACRES ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANDAN
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58554-3833
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-281-0528
Provider Business Mailing Address Fax Number:
701-255-4495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 SHADY ACRES ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANDAN
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58554-3833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-281-0528
Provider Business Practice Location Address Fax Number:
701-255-4495
Provider Enumeration Date:
03/13/2015

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: 101YM0800X , with the licence number:  825-3-1-15A , 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)





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