Healthcare Provider Details

I. General information

NPI: 1861497190
Provider Name (Legal Business Name): JESOLA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 12/10/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 8TH ST SE STE A
DETROIT LAKES MN
56501-2819
US

IV. Provider business mailing address

1000 8TH ST SE STE A
DETROIT LAKES MN
56501-2819
US

V. Phone/Fax

Practice location:
  • Phone: 218-847-0696
  • Fax: 218-847-4198
Mailing address:
  • Phone: 218-847-0696
  • Fax: 218-847-4198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: JESSICA RAE MOENCH
Title or Position: OWNER/DIRECTOR
Credential: BS, LADC
Phone: 218-396-0288