Healthcare Provider Details

I. General information

NPI: 1902749344
Provider Name (Legal Business Name): JOLENE CORRINNE LAUTT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2026
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 65TH AVE S APT 312
FARGO ND
58104-7458
US

IV. Provider business mailing address

PO BOX 9064
FARGO ND
58106-9064
US

V. Phone/Fax

Practice location:
  • Phone: 701-680-1309
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: