Healthcare Provider Details

I. General information

NPI: 1871456632
Provider Name (Legal Business Name): JACQUELINE MARIE JENNISSEN ADC-T
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 CLOQUET AVE STE 117
CLOQUET MN
55720-1649
US

IV. Provider business mailing address

2101 WOODDALE DR STE B
WOODBURY MN
55125-4442
US

V. Phone/Fax

Practice location:
  • Phone: 218-879-5545
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3126
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: