Provider Demographics
NPI:1043385032
Name:FAUL, JENNIFER JO (LCSW IN ND LGSW IN M)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:JO
Last Name:FAUL
Suffix:
Gender:F
Credentials:LCSW IN ND LGSW IN M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 111
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:ND
Mailing Address - Zip Code:58021
Mailing Address - Country:US
Mailing Address - Phone:701-371-6550
Mailing Address - Fax:
Practice Address - Street 1:2925 20TH ST S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560
Practice Address - Country:US
Practice Address - Phone:218-284-0300
Practice Address - Fax:218-284-5944
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND29941041C0700X
MN112331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10677Medicaid
MN338K3FAOtherBCBS
ND24450Medicare ID - Type Unspecified