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NPI Code Detail

MEDICARE: JENA HAGGITH LADC, BS

MEDICARE: JENA HAGGITH LADC, BS
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
1101YA0400XAddiction (Substance Use Disorder) Counselor303684MN

General Provider Information

NPI Number : 1689089237
Entity Type Code : Individual
Provider Name (Legal Business Name) : JENA HAGGITH LADC, BS
Provider Business Mailing Address
First Line : 1316 BOARDWALK AVE
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55411-3364
Country : US
Telephone Number : 262-894-1089
Fax Number :
Provider Business Practice Location Address
First Line : 1901 44TH AVE N
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55412-1209
Country : US
Telephone Number : 612-677-2671
Fax Number : 612-767-6603
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/23/2014
Last Update Date : 06/23/2014

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