Healthcare Provider Details

I. General information

NPI: 1538218391
Provider Name (Legal Business Name): JANE CHARLOTTE GAFFREY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANE CHARLOTTE HUDSON D.O.

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 4TH ST S
FARGO ND
58103-1929
US

IV. Provider business mailing address

100 4TH ST S
FARGO ND
58103-1929
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-4141
  • Fax: 701-234-4137
Mailing address:
  • Phone: 701-234-4141
  • Fax: 701-234-4137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number10095
License Number StateND

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: