Provider Demographics
NPI:1225633530
Name:PAKKALA, JADE
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:PAKKALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JADE
Other - Middle Name:
Other - Last Name:KUNISHIGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3911 20TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4705
Mailing Address - Country:US
Mailing Address - Phone:701-235-7341
Mailing Address - Fax:
Practice Address - Street 1:1905 2ND ST SE STE 1B
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-6566
Practice Address - Country:US
Practice Address - Phone:701-838-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
ND00000171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174400000XOther Service ProvidersSpecialist