Provider Demographics
NPI:1073883773
Name:ANDERSON, JAMIE (LAPC)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 45TH ST S STE A
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8970
Mailing Address - Country:US
Mailing Address - Phone:701-356-4384
Mailing Address - Fax:
Practice Address - Street 1:3401 45TH ST S STE A
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8970
Practice Address - Country:US
Practice Address - Phone:013-564-3847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND706-12-15-11A101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1462276Medicaid