Provider Demographics
NPI:1891206215
Name:HEDSTROM, JACQUELYN ANN (DNP APRN PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:ANN
Last Name:HEDSTROM
Suffix:
Gender:F
Credentials:DNP APRN PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11506 FREDLUND RD
Mailing Address - Street 2:
Mailing Address - City:HETTINGER
Mailing Address - State:ND
Mailing Address - Zip Code:58639-9271
Mailing Address - Country:US
Mailing Address - Phone:701-928-0305
Mailing Address - Fax:
Practice Address - Street 1:1000 HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:HETTINGER
Practice Address - State:ND
Practice Address - Zip Code:58639-7530
Practice Address - Country:US
Practice Address - Phone:701-567-4561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR20596363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health