Provider Demographics
NPI:1326379082
Name:KANE, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 25TH ST S
Mailing Address - Street 2:PO BOX 9859
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2311
Mailing Address - Country:US
Mailing Address - Phone:701-746-4584
Mailing Address - Fax:
Practice Address - Street 1:1726 S WASHINGTON ST
Practice Address - Street 2:SUITE 33A
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6370
Practice Address - Country:US
Practice Address - Phone:701-746-7584
Practice Address - Fax:701-746-1239
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3965104100000X
MN15556104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker