Provider Demographics
NPI:1427131713
Name:JOHN, JENIFER ELIZABETH (MA LMFT LICSW)
Entity type:Individual
Prefix:
First Name:JENIFER
Middle Name:ELIZABETH
Last Name:JOHN
Suffix:
Gender:F
Credentials:MA LMFT LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 E BROADWAY ST
Mailing Address - Street 2:PO BOX 1342
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-9317
Mailing Address - Country:US
Mailing Address - Phone:763-232-7403
Mailing Address - Fax:763-262-1113
Practice Address - Street 1:261 BROADWAY ST E
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362
Practice Address - Country:US
Practice Address - Phone:763-262-3077
Practice Address - Fax:763-262-1113
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN074481041C0700X
MN0875106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
46P17COOtherBCBS
MN6267051OtherUBH
MN390C5JOOtherBCBS