Provider Demographics
NPI:1285486688
Name:KIESENDAHL, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KIESENDAHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 ROCKY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:HAWLEY
Mailing Address - State:PA
Mailing Address - Zip Code:18428-4535
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:187 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:HAWLEY
Practice Address - State:PA
Practice Address - Zip Code:18428-7003
Practice Address - Country:US
Practice Address - Phone:570-226-4557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW141230104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker