Provider Demographics
NPI:1972791317
Name:SENN, JEREMY JOHN (MA,LPC,LAC,NCC,MAC)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:JOHN
Last Name:SENN
Suffix:
Gender:M
Credentials:MA,LPC,LAC,NCC,MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4076 NEELY ROAD
Mailing Address - Street 2:BLDG 4076, ROOM 3C-401
Mailing Address - City:FT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4076 NEELY ROAD
Practice Address - Street 2:BLDG 4076, ROOM 3C-401
Practice Address - City:FT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703
Practice Address - Country:US
Practice Address - Phone:907-384-0405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO200101YA0400X
CO4772101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional