Healthcare Provider Details

I. General information

NPI: 1407909120
Provider Name (Legal Business Name): BRIAN V JONGEWARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 02/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2812 17TH AVE S STE C
GRAND FORKS ND
58201-4048
US

IV. Provider business mailing address

2812 17TH AVE S STE C
GRAND FORKS ND
58201-4048
US

V. Phone/Fax

Practice location:
  • Phone: 701-775-0223
  • Fax: 701-738-0655
Mailing address:
  • Phone: 701-775-0223
  • Fax: 701-738-0655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number611
License Number StateND

VIII. Authorized Official

Name: DR. BRIAN V JONGEWARD
Title or Position: OWNER DOCTOR
Credential: DC
Phone: 701-775-0223