Provider Demographics
NPI:1871523274
Name:HAGEN, JOLEEN R
Entity type:Individual
Prefix:
First Name:JOLEEN
Middle Name:R
Last Name:HAGEN
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 1:419 5TH ST NE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-3300
Mailing Address - Country:US
Mailing Address - Phone:701-252-1050
Mailing Address - Fax:701-952-3265
Practice Address - Street 1:419 5TH ST NE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-3300
Practice Address - Country:US
Practice Address - Phone:701-252-1050
Practice Address - Fax:701-952-3265
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND676133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00411343OtherRR MEDICARE
26957OtherBLUE SHIELD
HP64722OtherHEALTH PARTNERS
6300416OtherMEDICA
NDN712003Medicare PIN