Provider Demographics
NPI:1679173751
Name:UNDERDAHL, JESSICA (BS)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:UNDERDAHL
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 TEXAS AVE NW APT F8
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350-1567
Mailing Address - Country:US
Mailing Address - Phone:952-261-6131
Mailing Address - Fax:
Practice Address - Street 1:85 MECHANIC ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-1537
Practice Address - Country:US
Practice Address - Phone:036-448-5610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3077550Medicaid