Provider Demographics
NPI:1114050465
Name:MIDGARDEN, JACKIE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:
Last Name:MIDGARDEN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:ND
Mailing Address - Zip Code:58237-1379
Mailing Address - Country:US
Mailing Address - Phone:701-352-2574
Mailing Address - Fax:701-352-0188
Practice Address - Street 1:830 W 15TH ST
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:ND
Practice Address - Zip Code:58237-2055
Practice Address - Country:US
Practice Address - Phone:701-352-1739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND434235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND58909Medicaid