Healthcare Provider Details

I. General information

NPI: 1962252338
Provider Name (Legal Business Name): JESSI ANN POLK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2024
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1542 16TH ST W STE 300
WILLISTON ND
58801-3888
US

IV. Provider business mailing address

PO BOX 334
ROZET WY
82727-0334
US

V. Phone/Fax

Practice location:
  • Phone: 701-572-2470
  • Fax:
Mailing address:
  • Phone: 701-290-2871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number52887
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: