Provider Demographics
NPI:1194964890
Name:JONGEKRYG, KELLI MARIE (BA)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE
Last Name:JONGEKRYG
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1833 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-2424
Mailing Address - Country:US
Mailing Address - Phone:763-421-5535
Mailing Address - Fax:763-433-0226
Practice Address - Street 1:2115 COUNTY ROAD D E # B
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-5353
Practice Address - Country:US
Practice Address - Phone:651-748-5019
Practice Address - Fax:651-773-7591
Is Sole Proprietor?:No
Enumeration Date:2009-02-19
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MN2601106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health