Provider Demographics
NPI:1114668829
Name:WIDNER, JEFFREY SCOTT (LICSW)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:SCOTT
Last Name:WIDNER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 4TH ST NW STE 115
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-3155
Mailing Address - Country:US
Mailing Address - Phone:218-214-9389
Mailing Address - Fax:218-517-2034
Practice Address - Street 1:403 4TH ST NW STE 115
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3155
Practice Address - Country:US
Practice Address - Phone:218-214-9389
Practice Address - Fax:218-517-2034
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN294101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical