Healthcare Provider Details

I. General information

NPI: 1427245372
Provider Name (Legal Business Name): JACKSON W LIND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 25TH ST S SUITE I
FARGO ND
58103-6104
US

IV. Provider business mailing address

2301 25TH ST S SUITE I
FARGO ND
58103-6104
US

V. Phone/Fax

Practice location:
  • Phone: 701-241-9300
  • Fax: 701-235-4525
Mailing address:
  • Phone: 701-241-9300
  • Fax: 701-235-4525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number2756
License Number StateND

VIII. Authorized Official

Name: DR. JACKSON W LIND
Title or Position: PRESIDENT
Credential: M.D.
Phone: 701-241-9300