Provider Demographics
NPI:1184024135
Name:JEAN C. CHRISTENSEN
Entity Type:Organization
Organization Name:JEAN C. CHRISTENSEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRANBOIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-444-6912
Mailing Address - Street 1:403 4TH ST NW STE 245
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-3134
Mailing Address - Country:US
Mailing Address - Phone:218-444-6912
Mailing Address - Fax:
Practice Address - Street 1:403 4TH ST NW STE 245
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3134
Practice Address - Country:US
Practice Address - Phone:218-444-6912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEAN CHRISTENSEN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3903251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN680002653Medicare PIN