Provider Demographics
NPI:1265653653
Name:CROATT NIEMI, JESSICA RAE (LICSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAE
Last Name:CROATT NIEMI
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:RAE
Other - Last Name:CROATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:515 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:PARK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56470-1210
Mailing Address - Country:US
Mailing Address - Phone:218-366-9229
Mailing Address - Fax:218-237-2520
Practice Address - Street 1:1426 BEMIDJI AVE N STE 1
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3882
Practice Address - Country:US
Practice Address - Phone:218-444-2233
Practice Address - Fax:218-237-2520
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN151241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN048937900Medicaid
MN201J8NIOtherBLUECROSSBLUESHIELD MN