Provider Demographics
NPI:1205903812
Name:MARRIAGE & FAMILY WELLNES CENTER, INC
Entity type:Organization
Organization Name:MARRIAGE & FAMILY WELLNES CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:JAMISON
Authorized Official - Suffix:
Authorized Official - Credentials:MDIV, MS, DMIN,
Authorized Official - Phone:507-288-3118
Mailing Address - Street 1:2801 55TH ST NW
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-4187
Mailing Address - Country:US
Mailing Address - Phone:507-288-3118
Mailing Address - Fax:
Practice Address - Street 1:2801 55TH ST NW
Practice Address - Street 2:SUITE 2
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-4187
Practice Address - Country:US
Practice Address - Phone:507-288-3118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN175106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1750387197Other101YMO800X