Healthcare Provider Details

I. General information

NPI: 1568102788
Provider Name (Legal Business Name): JENNA L KAVANAGH LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 30TH AVE W
ALEXANDRIA MN
56308-3429
US

IV. Provider business mailing address

516 N SHORE DR APT 3
BATTLE LAKE MN
56515-4070
US

V. Phone/Fax

Practice location:
  • Phone: 320-460-8028
  • Fax:
Mailing address:
  • Phone: 701-261-7911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number305726
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: