MEDICARE: JESS NOWAK JR.

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	25704	MN

General Provider Information

NPI Number	:	1982230744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESS NOWAK JR.

Provider Business Mailing Address
First Line	:	102 MARTY DR STE 2
Second Line	:
City	:	BUFFALO
State	:	MN
Zip	:	55313-9345
Country	:	US
Telephone Number	:	763-682-5420
Fax Number	:	763-682-5803

Provider Business Practice Location Address
First Line	:	102 MARTY DR STE 2
Second Line	:
City	:	BUFFALO
State	:	MN
Zip	:	55313-9345
Country	:	US
Telephone Number	:	763-682-5420
Fax Number	:	763-682-5803

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

Provider Enumeration Date	:	03/12/2020
Last Update Date	:	03/12/2020

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Directions to “ JESS NOWAK JR. ” Practice Location

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