Healthcare Provider Details

I. General information

NPI: 1154237774
Provider Name (Legal Business Name): JYOTI RAI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2026
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 SAN JUAN DR S
FARGO ND
58103-1049
US

IV. Provider business mailing address

426 SAN JUAN DR S
FARGO ND
58103-1049
US

V. Phone/Fax

Practice location:
  • Phone: 701-730-9213
  • Fax:
Mailing address:
  • Phone: 701-730-9213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number1475330
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: