Provider Demographics
NPI:1265637250
Name:DRISCOLL, JEAN ANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:ANN
Last Name:DRISCOLL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 N 40TH ST APT 105K
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58203-8513
Mailing Address - Country:US
Mailing Address - Phone:701-317-6487
Mailing Address - Fax:017-317-6487
Practice Address - Street 1:715 N 40TH ST APT 105K
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58203
Practice Address - Country:US
Practice Address - Phone:701-317-6487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN238011041C0700X
ND40151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19310Medicaid