Healthcare Provider Details

I. General information

NPI: 1982425609
Provider Name (Legal Business Name): JILLENE SUSAG ED. S., NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2024
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 4TH ST W
DICKINSON ND
58601-4951
US

IV. Provider business mailing address

444 4TH ST W
DICKINSON ND
58601-4951
US

V. Phone/Fax

Practice location:
  • Phone: 701-456-0002
  • Fax:
Mailing address:
  • Phone: 701-456-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number417190
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: