Provider Demographics
NPI:1417490160
Name:KANWISCHER-JAGIM, KATRINA
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:KANWISCHER-JAGIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 CINNAMON RIDGE PL
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-8190
Mailing Address - Country:US
Mailing Address - Phone:218-303-5829
Mailing Address - Fax:
Practice Address - Street 1:835 CINNAMON RIDGE PL
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-8190
Practice Address - Country:US
Practice Address - Phone:218-303-5829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X, 174400000X
ND2016-036A106H00000X
ND2019-071106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No174400000XOther Service ProvidersSpecialist