Healthcare Provider Details

I. General information

NPI: 1992140164
Provider Name (Legal Business Name): MOLLY JANSSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 05/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 4TH ST
BROOKINGS SD
57006-1917
US

IV. Provider business mailing address

211 4TH ST
BROOKINGS SD
57006-1917
US

V. Phone/Fax

Practice location:
  • Phone: 605-697-2874
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: