Healthcare Provider Details

I. General information

NPI: 1740871201
Provider Name (Legal Business Name): CREATIVE JOURNEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2021
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 5TH ST NE STE 142
JAMESTOWN ND
58401-3318
US

IV. Provider business mailing address

419 5TH ST NE STE 142
JAMESTOWN ND
58401-3318
US

V. Phone/Fax

Practice location:
  • Phone: 701-658-9032
  • Fax:
Mailing address:
  • Phone: 701-658-9032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SHAULEE A IVERSON
Title or Position: OWNER/PRESIDENT
Credential: MS OTR/L
Phone: 701-658-9032