Provider Demographics
NPI:1265824296
Name:JANSON-WOLLE, KENZIE (MSW, AASW)
Entity Type:Individual
Prefix:
First Name:KENZIE
Middle Name:
Last Name:JANSON-WOLLE
Suffix:
Gender:F
Credentials:MSW, AASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9245 QUANTRELLE AVE NE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55330-0168
Mailing Address - Country:US
Mailing Address - Phone:763-746-9492
Mailing Address - Fax:
Practice Address - Street 1:9245 QUANTRELLE AVE NE
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55330-0168
Practice Address - Country:US
Practice Address - Phone:763-746-9492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-27
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 390200000X
MN287101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program