Provider Demographics
NPI:1770776783
Name:JESSEN, MARIAH DUSE (MS CCCSLP)
Entity type:Individual
Prefix:MRS
First Name:MARIAH
Middle Name:DUSE
Last Name:JESSEN
Suffix:
Gender:F
Credentials:MS CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 32ND AVE S
Mailing Address - Street 2:SUITE 9
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6163
Mailing Address - Country:US
Mailing Address - Phone:701-232-2340
Mailing Address - Fax:701-232-2330
Practice Address - Street 1:3003 32ND AVE S
Practice Address - Street 2:SUITE 9
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6163
Practice Address - Country:US
Practice Address - Phone:701-232-2340
Practice Address - Fax:701-232-2330
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP38X235Z00000X
ND1065235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1770688871Medicaid