Provider Demographics
NPI:1609630953
Name:MITTLEIDER, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MITTLEIDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 NORTH AVE NE
Mailing Address - Street 2:
Mailing Address - City:TAPPEN
Mailing Address - State:ND
Mailing Address - Zip Code:58487-8731
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:245 NORTH AVE NE
Practice Address - Street 2:
Practice Address - City:TAPPEN
Practice Address - State:ND
Practice Address - Zip Code:58487-8731
Practice Address - Country:US
Practice Address - Phone:701-368-8123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND41155376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide