Healthcare Provider Details

I. General information

NPI: 1487157855
Provider Name (Legal Business Name): MYSTE JO NELSEN HUTTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 DIVISION AVE
GRAND FORKS ND
58201-4702
US

IV. Provider business mailing address

2607 OLIVE ST
GRAND FORKS ND
58201-7054
US

V. Phone/Fax

Practice location:
  • Phone: 218-791-9539
  • Fax:
Mailing address:
  • Phone: 218-791-5935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number135587
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number29796
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number5460
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: