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General NPI Number Information
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NPI Number | 1861497190
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Entity Type | Organization
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Legal Business Name | JESOLA INC
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Dates
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Enumeration Date | 06/14/2005
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Last Update Date | 12/10/2024
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Provider Practice Location Address
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Address Line | 1000 8TH ST SE STE A
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City | DETROIT LAKES
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State | MN
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Zip | 56501-2819
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Country | US
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Telephone | 218-847-0696
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Fax | 218-847-4198
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Provider Business Mailing Address
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Address Line | 1000 8TH ST SE STE A
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City | DETROIT LAKES
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State | MN
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Zip | 56501-2819
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Country | US
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Telephone | 218-847-0696
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Fax | 218-847-4198
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Authorized Official
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Title or Position | OWNER/DIRECTOR
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Name | JESSICA RAE MOENCH
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Credential | BS, LADC
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Telephone | 218-396-0288
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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 |
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License Number State |
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