=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720589856
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA ANN KARASEK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2018
-----------------------------------------------------
Last Update Date | 02/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10342 HIGHWAY 133
-----------------------------------------------------
City | MEADOWLANDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55765-8133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-590-7217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 57
-----------------------------------------------------
City | MEADOWLANDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55765-0057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-590-7217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253J00000X
-----------------------------------------------------
Taxonomy Name | Foster Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------