Healthcare Provider Details

I. General information

NPI: 1811083439
Provider Name (Legal Business Name): JENELLE SLOBOF LICSW/LCSW-BACS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 JAMES CT
SAINT PAUL MN
55118-3640
US

IV. Provider business mailing address

1016 JAMES CT
SAINT PAUL MN
55118-3640
US

V. Phone/Fax

Practice location:
  • Phone: 561-308-5904
  • Fax:
Mailing address:
  • Phone: 561-308-5904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number11655
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW7155
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11928
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: