Provider Demographics
NPI:1790124469
Name:GERMAIN, JOLENE
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:
Last Name:GERMAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOLENE
Other - Middle Name:
Other - Last Name:KNEEBONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1547 30TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5149
Mailing Address - Country:US
Mailing Address - Phone:218-287-4338
Mailing Address - Fax:218-287-5928
Practice Address - Street 1:1547 30TH AVE S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5149
Practice Address - Country:US
Practice Address - Phone:218-287-4338
Practice Address - Fax:218-287-5928
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
1-19-38492103K00000X, 103K00000X
NDL61103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174400000XOther Service ProvidersSpecialist