Provider Demographics
NPI:1104673193
Name:WHITAKER, JESSICA ANN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 ROBERTS ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4716
Mailing Address - Country:US
Mailing Address - Phone:701-404-9180
Mailing Address - Fax:701-936-6621
Practice Address - Street 1:2306 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4932
Practice Address - Country:US
Practice Address - Phone:701-425-6618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist