Provider Demographics
NPI:1245541895
Name:JALLEN, STEPHANIE (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:JALLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 997
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58502-0997
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4520
Practice Address - Country:US
Practice Address - Phone:701-530-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND136952084P0804X
FLME1168742084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND81891Medicaid
NDN721617Medicare PIN