Provider Demographics
NPI:1851694806
Name:THEISEN, JANA LEE (LAC, LSW)
Entity Type:Individual
Prefix:
First Name:JANA
Middle Name:LEE
Last Name:THEISEN
Suffix:
Gender:F
Credentials:LAC, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 32ND AVE S STE 202
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6545
Mailing Address - Country:US
Mailing Address - Phone:701-746-6336
Mailing Address - Fax:701-772-1030
Practice Address - Street 1:2424 32ND AVE S STE 202
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6545
Practice Address - Country:US
Practice Address - Phone:701-746-6336
Practice Address - Fax:701-772-1030
Is Sole Proprietor?:No
Enumeration Date:2010-12-14
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1598101YA0400X
ND4196104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker