MEDICARE: MRS. JESSICA MARIE MOUND LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	P013027	SD

General Provider Information

NPI Number	:	1154160687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA MARIE MOUND LPN

Provider Business Mailing Address
First Line	:	816 10TH AVE W
Second Line	:
City	:	MOBRIDGE
State	:	SD
Zip	:	57601-1942
Country	:	US
Telephone Number	:	605-848-4382
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 STANDING ROCK AVE
Second Line	:
City	:	FORT YATES
State	:	ND
Zip	:	58538-8528
Country	:	US
Telephone Number	:	701-854-3831
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2024
Last Update Date	:	05/23/2024

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