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General NPI Number Information
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NPI Number | 1578288403
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Entity Type | Individual
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Provider Name | JENNIFER CONNOLLY LADC
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Gender | Female
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Dates
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Enumeration Date | 10/04/2022
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Last Update Date | 10/04/2022
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Provider Practice Location Address
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Address Line | 11660 ROUND LAKE BLVD NW
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City | COON RAPIDS
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State | MN
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Zip | 55433-2638
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Country | US
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Telephone | 763-767-3350
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Fax |
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Provider Business Mailing Address
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Address Line | 11452 KENYON CT NE
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City | BLAINE
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State | MN
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Zip | 55449-5480
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Country | US
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Telephone | 612-272-7953
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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 | 305835
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License Number State | MN
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