Provider Demographics
NPI:1356799209
Name:HUBER, JACQUELINE (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:HUBER
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 1:1810 39TH ST S APT 206
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4419
Mailing Address - Country:US
Mailing Address - Phone:701-220-0560
Mailing Address - Fax:
Practice Address - Street 1:111 W VERNON AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2741
Practice Address - Country:US
Practice Address - Phone:218-739-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN673562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program