Healthcare Provider Details

I. General information

NPI: 1205764065
Provider Name (Legal Business Name): JENNA MCKENZIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA PHIPPS

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 NORTHLAND DR
MENDOTA HEIGHTS MN
55120-1288
US

IV. Provider business mailing address

1155 NORTHLAND DR
MENDOTA HEIGHTS MN
55120-1288
US

V. Phone/Fax

Practice location:
  • Phone: 763-330-9225
  • Fax: 833-972-1118
Mailing address:
  • Phone: 763-330-9225
  • Fax: 833-972-1118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1174477350
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1164121976
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1972084226
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1962955302
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1962152827
License Number StateMN
# 6
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1194195248
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: