Healthcare Provider Details

I. General information

NPI: 1225176613
Provider Name (Legal Business Name): JESSE J KRIEGER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 01/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 1ST AVE NE
HAZEN ND
58545
US

IV. Provider business mailing address

PO BOX 1005
HAZEN ND
58545-1005
US

V. Phone/Fax

Practice location:
  • Phone: 701-748-6383
  • Fax:
Mailing address:
  • Phone: 701-748-6383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number474
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: