Provider Demographics
NPI:1114293941
Name:WATTERUD, JESSICA (LPCC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WATTERUD
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 136
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:ND
Mailing Address - Zip Code:58730-0136
Mailing Address - Country:US
Mailing Address - Phone:701-240-6971
Mailing Address - Fax:701-965-3522
Practice Address - Street 1:17 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:ND
Practice Address - Zip Code:58730-5873
Practice Address - Country:US
Practice Address - Phone:701-240-6971
Practice Address - Fax:701-965-3522
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ND228101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program