Provider Demographics
NPI:1275814253
Name:MALL, JEANENE MARIE (TLMFT)
Entity Type:Individual
Prefix:MRS
First Name:JEANENE
Middle Name:MARIE
Last Name:MALL
Suffix:
Gender:F
Credentials:TLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9504 W 104TH ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-5603
Mailing Address - Country:US
Mailing Address - Phone:913-206-8259
Mailing Address - Fax:
Practice Address - Street 1:7381 W 133RD ST
Practice Address - Street 2:SUITE 260
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213-4750
Practice Address - Country:US
Practice Address - Phone:913-647-8092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-02
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-LMFT 1261106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist