Healthcare Provider Details

I. General information

NPI: 1689588014
Provider Name (Legal Business Name): MERCEDES JUMP LAPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 19TH AVE NW
MINOT ND
58703-8899
US

IV. Provider business mailing address

PO BOX 5007
MINOT ND
58702-5007
US

V. Phone/Fax

Practice location:
  • Phone: 701-852-3628
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1591-9-15-26A
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: