Provider Demographics
NPI:1770710162
Name:WEISS, JERI RAE (LSE)
Entity type:Individual
Prefix:MS
First Name:JERI
Middle Name:RAE
Last Name:WEISS
Suffix:
Gender:F
Credentials:LSE
Other - Prefix:MS
Other - First Name:JERI
Other - Middle Name:RAE
Other - Last Name:PUCHANY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:316 2ND AVE W
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-5218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:316 2ND AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-5218
Practice Address - Country:US
Practice Address - Phone:701-774-4657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-12
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND952104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54516Medicaid