Provider Demographics
NPI:1023521077
Name:ROSSUM, JON KRISTIAN
Entity type:Individual
Prefix:
First Name:JON
Middle Name:KRISTIAN
Last Name:ROSSUM
Suffix:
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 1:2915 BLUESTEM DR APT 1180
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-8039
Mailing Address - Country:US
Mailing Address - Phone:651-356-0029
Mailing Address - Fax:
Practice Address - Street 1:647 13TH AVE E STE A
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-3328
Practice Address - Country:US
Practice Address - Phone:701-277-8844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician