Provider Demographics
NPI:1013001114
Name:WITTE-BAKKEN, JAN KAREN (PHD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:KAREN
Last Name:WITTE-BAKKEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:891 BELSLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5055
Mailing Address - Country:US
Mailing Address - Phone:218-287-4338
Mailing Address - Fax:218-287-5928
Practice Address - Street 1:891 BELSLY BLVD
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5055
Practice Address - Country:US
Practice Address - Phone:218-287-4338
Practice Address - Fax:218-287-5928
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2205103TC0700X
ND306103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18691OtherBLUE CROSS
ND11082OtherMEDICAID
MN505252100Medicaid
ND11082OtherMEDICAID
O58334Medicare UPIN