Provider Demographics
NPI:1891810974
Name:ANDERSEN, JESSE N (DC)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:N
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 E INTERSTATE AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0551
Mailing Address - Country:US
Mailing Address - Phone:701-222-8322
Mailing Address - Fax:701-222-8397
Practice Address - Street 1:1051 E INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0551
Practice Address - Country:US
Practice Address - Phone:701-222-8322
Practice Address - Fax:701-222-8397
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND757111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND25449OtherBCBS OF ND PROVIDER #
ND13406Medicaid
ND25449Medicare PIN
ND25449OtherBCBS OF ND PROVIDER #