Healthcare Provider Details

I. General information

NPI: 1356877963
Provider Name (Legal Business Name): JESSICA WALD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 21ST AVE NW SUITE B
MINOT ND
58703-0816
US

IV. Provider business mailing address

1425 21ST AVE NW SUITE B
MINOT ND
58703-0816
US

V. Phone/Fax

Practice location:
  • Phone: 701-328-3936
  • Fax: 701-857-7724
Mailing address:
  • Phone: 701-328-3936
  • Fax: 701-857-7724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: