Provider Demographics
NPI:1871270975
Name:ULMER, MCKENZIE JADE
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:JADE
Last Name:ULMER
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 1:1202 WESTRAC DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2338
Mailing Address - Country:US
Mailing Address - Phone:701-365-1776
Mailing Address - Fax:
Practice Address - Street 1:1202 WESTRAC DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2338
Practice Address - Country:US
Practice Address - Phone:701-365-1776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
ND171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174400000XOther Service ProvidersSpecialist