Provider Demographics
NPI:1134579139
Name:FETSCH, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FETSCH
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 1:1726 S WASHINGTON ST STE 33A
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6395
Mailing Address - Country:US
Mailing Address - Phone:701-746-4584
Mailing Address - Fax:
Practice Address - Street 1:1726 S WASHINGTON ST STE 33A
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6395
Practice Address - Country:US
Practice Address - Phone:701-746-4584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN216601041C0700X
ND44371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical