Provider Demographics
NPI:1336998814
Name:WHITE, JENNY MARIE
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:MARIE
Last Name:WHITE
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 1:14599 83RD ST NE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55330-6613
Mailing Address - Country:US
Mailing Address - Phone:763-242-1438
Mailing Address - Fax:
Practice Address - Street 1:1262 CEDAR ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8913
Practice Address - Country:US
Practice Address - Phone:763-732-3351
Practice Address - Fax:763-322-5026
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4559106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist