Provider Demographics
NPI:1861497190
Name:JESOLA INC
Entity type:Organization
Organization Name:JESOLA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:MOENCH
Authorized Official - Suffix:
Authorized Official - Credentials:BS, LADC
Authorized Official - Phone:218-396-0288
Mailing Address - Street 1:1000 8TH ST SE
Mailing Address - Street 2:STE A
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-2819
Mailing Address - Country:US
Mailing Address - Phone:218-847-0696
Mailing Address - Fax:218-847-4198
Practice Address - Street 1:1000 8TH ST SE
Practice Address - Street 2:STE A
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-2819
Practice Address - Country:US
Practice Address - Phone:218-847-0696
Practice Address - Fax:218-847-4198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN903109000Medicaid