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NPI Code Detail

MEDICARE: JADE RENEE THELEN

MEDICARE: JADE RENEE THELEN
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
1106S00000XBehavior Technician

General Provider Information

NPI Number : 1922674407
Entity Type Code : Individual
Provider Name (Legal Business Name) : JADE RENEE THELEN
Provider Business Mailing Address
First Line : 4152 30TH AVE S
Second Line :
City : FARGO
State : ND
Zip : 58104-8524
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4152 30TH AVE S
Second Line :
City : FARGO
State : ND
Zip : 58104-8524
Country : US
Telephone Number : 701-561-3049
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/03/2021
Last Update Date : 06/03/2021

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Directions to “ JADE RENEE THELEN ” Practice Location

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