Provider Demographics
NPI:1982230744
Name:NOWAK, JESS JR
Entity Type:Individual
Prefix:
First Name:JESS
Middle Name:
Last Name:NOWAK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 MARTY DR STE 2
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-9345
Mailing Address - Country:US
Mailing Address - Phone:763-682-5420
Mailing Address - Fax:763-682-5803
Practice Address - Street 1:102 MARTY DR STE 2
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-9345
Practice Address - Country:US
Practice Address - Phone:763-682-5420
Practice Address - Fax:763-682-5803
Is Sole Proprietor?:No
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN257041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical