MEDICARE: JEFFREY SCOTT WIDNER LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	11755-123	WI
2	1041C0700X	Clinical Social Worker	29410	MN

General Provider Information

NPI Number	:	1114668829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY SCOTT WIDNER LICSW

Provider Business Mailing Address
First Line	:	403 4TH ST NW STE 115
Second Line	:
City	:	BEMIDJI
State	:	MN
Zip	:	56601-3155
Country	:	US
Telephone Number	:	218-214-9389
Fax Number	:	218-517-2034

Provider Business Practice Location Address
First Line	:	403 4TH ST NW STE 115
Second Line	:
City	:	BEMIDJI
State	:	MN
Zip	:	56601-3155
Country	:	US
Telephone Number	:	218-214-9389
Fax Number	:	218-517-2034

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2022
Last Update Date	:	05/31/2024

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