Active NPI
Jesse Logan Formanek, RBT
- Behavior Technician
- Saint Cloud, MN
National Provider Identifier
1306476502
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Behavior Technician
- License
- RBT-20-110353
- Practice address
- 3721 23Rd St S Apt 201
Saint Cloud, MN 56301-6199 - Phone
- (218) 457-2185
- Fax
- (605) 271-3956
- NPI assigned
- Jan 16, 2020
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Behavior Technician | 106S00000X | RBT-20-110353 | MN | Primary |
Addresses
Primary practice location
3721 23Rd St S Apt 201
Saint Cloud, MN 56301-6199
Mailing address
2804 E 26TH St Ste 1
Sioux Falls, SD 57103-4019
Phone (605) 271-2690
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| RBT-20-110353 | MN | MD | Behavior Technician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1579132800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1579132800000",
"number": "1306476502",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2804 E 26TH ST STE 1",
"city": "SIOUX FALLS",
"state": "SD",
"postal_code": "571034019",
"telephone_number": "605-271-2690",
"fax_number": "605-271-3956"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3721 23RD ST S APT 201",
"city": "SAINT CLOUD",
"state": "MN",
"postal_code": "563016199",
"telephone_number": "218-457-2185",
"fax_number": "605-271-3956"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FORMANEK",
"first_name": "JESSE",
"middle_name": "LOGAN",
"credential": "RBT",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2020-01-16",
"last_updated": "2020-01-16",
"certification_date": "2020-01-16",
"status": "A"
},
"taxonomies": [
{
"code": "106S00000X",
"taxonomy_group": "",
"desc": "Behavior Technician",
"state": "MN",
"license": "RBT-20-110353",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Saint Cloud, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 16, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.