Provider Demographics
NPI:1417001033
Name:LANDPHERE, JENNIFER (BS, LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LANDPHERE
Suffix:
Gender:F
Credentials:BS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 7TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1821
Mailing Address - Country:US
Mailing Address - Phone:701-293-3384
Mailing Address - Fax:701-293-3759
Practice Address - Street 1:409 7TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1821
Practice Address - Country:US
Practice Address - Phone:701-293-3384
Practice Address - Fax:701-293-3759
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1510101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)