Provider Demographics
NPI:1699349084
Name:WISETH, JADE
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:WISETH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JADE
Other - Middle Name:
Other - Last Name:MANNIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1811 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6337
Mailing Address - Country:US
Mailing Address - Phone:701-757-3045
Mailing Address - Fax:
Practice Address - Street 1:1811 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6337
Practice Address - Country:US
Practice Address - Phone:701-757-3045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1945235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1945OtherST LICENSE