=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114485364
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA ALICE FREUDENTHAL NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2019
-----------------------------------------------------
Last Update Date | 03/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1325 S CLIFF AVE
-----------------------------------------------------
City | SIOUX FALLS
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57105-1007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-322-8988
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 W WALNUT ST
-----------------------------------------------------
City | PARKSTON
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57366-2149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-343-5322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | CP001540
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------