Provider Demographics
NPI:1376090365
Name:BATES, JEFFREY (LPC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:BATES
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3453 INTERSTATE BLVD S STE B
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2257
Mailing Address - Country:US
Mailing Address - Phone:701-289-4354
Mailing Address - Fax:701-205-4593
Practice Address - Street 1:1351 PAGE DR S STE 104
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3536
Practice Address - Country:US
Practice Address - Phone:701-429-4724
Practice Address - Fax:701-532-0788
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND792-7-15-14101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional