Healthcare Provider Details

I. General information

NPI: 1528229051
Provider Name (Legal Business Name): JACQUELINE GAYLE TESKEY LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE GAYLE COLBY LSW

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 2ND AVE W
WILLISTON ND
58801-5218
US

IV. Provider business mailing address

316 2ND AVE W
WILLISTON ND
58801-5218
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-4600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1855
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: