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General NPI Number Information
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NPI Number | 1275243552
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Entity Type | Individual
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Provider Name | JODIE M EVENSON LADC
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Gender | Female
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Dates
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Enumeration Date | 11/28/2022
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Last Update Date | 11/28/2022
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Provider Practice Location Address
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Address Line | 206 MAPLE AVE E
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City | MORA
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State | MN
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Zip | 55051-1311
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Country | US
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Telephone | 320-209-1941
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Fax |
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Provider Business Mailing Address
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Address Line | 665 5TH AVE NW
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City | PINE CITY
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State | MN
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Zip | 55063-1020
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Country | US
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Telephone | 320-209-1941
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 306374
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License Number State | MN
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