Provider Demographics
NPI:1962174169
Name:DECKER, JENNIFER (MA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DECKER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56619-0430
Mailing Address - Country:US
Mailing Address - Phone:218-444-2845
Mailing Address - Fax:218-444-2847
Practice Address - Street 1:519 ANNE ST NW STE B
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-4278
Practice Address - Country:US
Practice Address - Phone:218-444-2845
Practice Address - Fax:218-444-2847
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4185106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist