Healthcare Provider Details

I. General information

NPI: 1891206215
Provider Name (Legal Business Name): JACQUELYN ANN HEDSTROM DNP APRN PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2017
Last Update Date: 10/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HIGHWAY 12
HETTINGER ND
58639-7530
US

IV. Provider business mailing address

11506 FREDLUND RD
HETTINGER ND
58639-9271
US

V. Phone/Fax

Practice location:
  • Phone: 701-567-4561
  • Fax:
Mailing address:
  • Phone: 701-928-0305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR20596
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: