Provider Demographics
NPI:1831135185
Name:CRAWFORD, JACQUELINE JANETTE (LP)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:JANETTE
Last Name:CRAWFORD
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10265
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58106-0265
Mailing Address - Country:US
Mailing Address - Phone:218-233-7524
Mailing Address - Fax:218-233-8627
Practice Address - Street 1:1010 32ND AVE S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5001
Practice Address - Country:US
Practice Address - Phone:218-233-7524
Practice Address - Fax:218-233-8627
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN 2508103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN116409OtherUCARE
MN1010730OtherPREFERRED ONE
MN62-24810OtherUBH
MN7H222CROtherBLUE CROSS BLUE SHIELD MN
MNHP23073OtherHEALTHPARTNERS