Healthcare Provider Details

I. General information

NPI: 1548530280
Provider Name (Legal Business Name): JESSICA MARIE MERTZ LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA MARIE CLAUSEN M.A., MSW

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7151 15TH ST S
FARGO ND
58104-6613
US

IV. Provider business mailing address

7151 15TH ST S
FARGO ND
58104-6613
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-2950
  • Fax: 701-364-2953
Mailing address:
  • Phone: 701-364-2950
  • Fax: 701-364-2953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4490
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier4490
Identifier TypeOTHER
Identifier StateND
Identifier IssuerLICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: