Provider Demographics
NPI:1104132505
Name:MOENCH, JESSICA RAE (LADC, OWNER/DIRECTOR)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAE
Last Name:MOENCH
Suffix:
Gender:F
Credentials:LADC, OWNER/DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 8TH ST SE STE A
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-2819
Mailing Address - Country:US
Mailing Address - Phone:218-847-0696
Mailing Address - Fax:218-847-4198
Practice Address - Street 1:1000 8TH ST SE STE A
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-2819
Practice Address - Country:US
Practice Address - Phone:218-847-0696
Practice Address - Fax:218-847-4198
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302886101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)