Healthcare Provider Details

I. General information

NPI: 1679197602
Provider Name (Legal Business Name): JESSICA WALDEMARSEN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2020
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 INDUSTRIAL DR SW
WILLMAR MN
56201-2989
US

IV. Provider business mailing address

PO BOX 284
WILLMAR MN
56201-0200
US

V. Phone/Fax

Practice location:
  • Phone: 320-212-8481
  • Fax: 320-200-7480
Mailing address:
  • Phone: 320-212-8481
  • Fax: 320-200-7480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number28179
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: