Provider Demographics
NPI:1669522421
Name:AAFEDT MCCOY, JANE ELISABETH (MOTRL)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:ELISABETH
Last Name:AAFEDT MCCOY
Suffix:
Gender:F
Credentials:MOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 11TH ST. SO.
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-7417
Mailing Address - Country:US
Mailing Address - Phone:701-356-0062
Mailing Address - Fax:701-356-5412
Practice Address - Street 1:3001 11TH ST. SO.
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-7417
Practice Address - Country:US
Practice Address - Phone:701-356-0062
Practice Address - Fax:701-356-5412
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND947225XP0200X
MN103187225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND55004Medicaid
ND27405OtherBCBS ND PROVIDER NUMBER