Provider Demographics
NPI:1841229648
Name:ANDERSEN, JASON (LAC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 S BROADWAY STE 18
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-4667
Mailing Address - Country:US
Mailing Address - Phone:701-857-8500
Mailing Address - Fax:701-857-8555
Practice Address - Street 1:1015 S BROADWAY STE 18
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4667
Practice Address - Country:US
Practice Address - Phone:701-857-8500
Practice Address - Fax:701-857-8555
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1474101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND054517Medicaid
ND020518OtherBCBS ND PIN