Provider Demographics
NPI:1154307072
Name:JENNER, SUSAN (MA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:JENNER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2042 KRAUSETOWN RD
Mailing Address - Street 2:
Mailing Address - City:OWENSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65066-2803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 N 1ST ST
Practice Address - Street 2:
Practice Address - City:OWENSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65066-1302
Practice Address - Country:US
Practice Address - Phone:573-437-2959
Practice Address - Fax:573-437-2974
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003020995101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor