Provider Demographics
NPI:1598832933
Name:JESSER, MARK (LSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:JESSER
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 13TH AVE W
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-4879
Mailing Address - Country:US
Mailing Address - Phone:701-227-7557
Mailing Address - Fax:701-227-7575
Practice Address - Street 1:300 13TH AVE W
Practice Address - Street 2:SUITE 1
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4879
Practice Address - Country:US
Practice Address - Phone:701-227-7557
Practice Address - Fax:701-227-7575
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1008104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54523Medicaid