MEDICARE: MARRIAGE & FAMILY WELLNES CENTER, INC

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	106H00000X	Marriage & Family Therapist	175	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1750387197	OTHER	MN	101YMO800X

General Provider Information

NPI Number	:	1205903812
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARRIAGE & FAMILY WELLNES CENTER, INC

Provider Business Mailing Address
First Line	:	2801 55TH ST NW
Second Line	:	SUITE 2
City	:	ROCHESTER
State	:	MN
Zip	:	55901-4187
Country	:	US
Telephone Number	:	507-288-3118
Fax Number	:

Provider Business Practice Location Address
First Line	:	2801 55TH ST NW
Second Line	:	SUITE 2
City	:	ROCHESTER
State	:	MN
Zip	:	55901-4187
Country	:	US
Telephone Number	:	507-288-3118
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DAVID L JAMISON
Credential	:	M.DIV, MS, D.MIN,
Telephone Number	:	507-288-3118

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	08/22/2020

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