MEDICARE: TAMMY JAN JEDLICKA MSW, LICSW

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	1041C0700X	Clinical Social Worker	13089	MN

General Provider Information

NPI Number	:	1982702361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMMY JAN JEDLICKA MSW, LICSW

Provider Business Mailing Address
First Line	:	16267 CARTER LAKE RD SE
Second Line	:
City	:	HINES
State	:	MN
Zip	:	56647-5778
Country	:	US
Telephone Number	:	218-586-2409
Fax Number	:	218-751-0253

Provider Business Practice Location Address
First Line	:	505 BEMIDJI AVE N STE 2
Second Line	:
City	:	BEMIDJI
State	:	MN
Zip	:	56601-3091
Country	:	US
Telephone Number	:	218-333-8496
Fax Number	:	218-751-0253

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/08/2007

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