Provider Demographics
NPI:1982702361
Name:JEDLICKA, TAMMY JAN (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:JAN
Last Name:JEDLICKA
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:16267 CARTER LAKE RD SE
Mailing Address - Street 2:
Mailing Address - City:HINES
Mailing Address - State:MN
Mailing Address - Zip Code:56647-5778
Mailing Address - Country:US
Mailing Address - Phone:218-586-2409
Mailing Address - Fax:218-751-0253
Practice Address - Street 1:505 BEMIDJI AVE N STE 2
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3091
Practice Address - Country:US
Practice Address - Phone:218-333-8496
Practice Address - Fax:218-751-0253
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN130891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical