Provider Demographics
NPI:1700826369
Name:WAALEN, JEANNE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:JEANNE
Middle Name:
Last Name:WAALEN
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 WOODHAVEN ST SW
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-3946
Mailing Address - Country:US
Mailing Address - Phone:701-364-3666
Mailing Address - Fax:
Practice Address - Street 1:4200 WOODHAVEN ST SW
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-3946
Practice Address - Country:US
Practice Address - Phone:701-364-3666
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC 0260363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant