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1063387298 NPI number — JADE WALLAT LGSW

NPI Number: 1063387298
Health Care Provider/Practitioner: JADE WALLAT LGSW

Information about “1063387298” NPI (JADE WALLAT LGSW) exists in 1063387298 in HTML format HTML  |  1063387298 in plain Text format TXT  |  1063387298 in PDF (Portable Document Format) PDF  |  1063387298 in an XML format XML  formats.

NPI Number : 1063387298 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1063387298",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "WALLAT",
    "FirstName": "JADE",
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "LGSW",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "9651 W RIVER RD",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "MINNEAPOLIS",
    "MailingAddressStateName": "MN",
    "MailingAddressPostalCode": "55444-1123",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": null,
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "13880 BUSINESS CENTER DR NW",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "ELK RIVER",
    "PracticeLocationAddressStateName": "MN",
    "PracticeLocationAddressPostalCode": "55330-1692",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "763-765-3800",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "10/07/2025",
    "LastUpdateDate": "10/07/2025",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "1041C0700X",
        "TaxonomyName": "Clinical Social Worker",
        "LicenseNumber": "24666",
        "LicenseNumberStateCode": "MN",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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