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General NPI Number Information
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NPI Number | 1568102788
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Entity Type | Individual
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Provider Name | JENNA L KAVANAGH LADC
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Gender | Female
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Dates
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Enumeration Date | 03/29/2022
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Last Update Date | 03/29/2022
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Provider Practice Location Address
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Address Line | 305 30TH AVE W
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City | ALEXANDRIA
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State | MN
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Zip | 56308-3429
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Country | US
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Telephone | 320-460-8028
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Fax |
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Provider Business Mailing Address
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Address Line | 516 N SHORE DR APT 3
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City | BATTLE LAKE
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State | MN
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Zip | 56515-4070
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Country | US
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Telephone | 701-261-7911
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 305726
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License Number State | MN
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