Provider Demographics
NPI:1558475061
Name:EVJEN, LORI MAE (LAC)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:MAE
Last Name:EVJEN
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:PO BOX 2055
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58402-2055
Mailing Address - Country:US
Mailing Address - Phone:701-253-6324
Mailing Address - Fax:701-253-6400
Practice Address - Street 1:520 3RD ST NW
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-2968
Practice Address - Country:US
Practice Address - Phone:701-253-6324
Practice Address - Fax:701-253-6400
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1490101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND022587OtherBCBS PROVIDER NUMBER