Healthcare Provider Details

I. General information

NPI: 1013347806
Provider Name (Legal Business Name): JENNA PRUSA LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2013
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 5TH ST SW
WILLMAR MN
56201-3216
US

IV. Provider business mailing address

420 KELLOGG AVE
AMES IA
50010-6226
US

V. Phone/Fax

Practice location:
  • Phone: 320-214-9692
  • Fax: 320-214-9924
Mailing address:
  • Phone: 515-233-2250
  • Fax: 515-233-3235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number20800
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: