Provider Demographics
NPI:1609400860
Name:JESSEN, DANE NELS
Entity Type:Individual
Prefix:
First Name:DANE
Middle Name:NELS
Last Name:JESSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 SUNNY LN
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-1349
Mailing Address - Country:US
Mailing Address - Phone:612-210-8415
Mailing Address - Fax:
Practice Address - Street 1:701 3RD ST NW
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-2963
Practice Address - Country:US
Practice Address - Phone:800-568-5175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician