Provider Demographics
NPI:1538502711
Name:SELK, JENNIFER H (LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:H
Last Name:SELK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1237 W DIVIDE AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1220
Mailing Address - Country:US
Mailing Address - Phone:701-328-8892
Mailing Address - Fax:701-328-8900
Practice Address - Street 1:1237 W DIVIDE AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501
Practice Address - Country:US
Practice Address - Phone:701-328-8892
Practice Address - Fax:701-328-8900
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)