Provider Demographics
NPI:1467027300
Name:KIMMINAU, JENNA MICHELE (LSW)
Entity Type:Individual
Prefix:MISS
First Name:JENNA
Middle Name:MICHELE
Last Name:KIMMINAU
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 E CENTER STREET EXT
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46582-3907
Mailing Address - Country:US
Mailing Address - Phone:574-267-1700
Mailing Address - Fax:
Practice Address - Street 1:3201 E CENTER STREET EXT
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46582-3907
Practice Address - Country:US
Practice Address - Phone:574-267-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN99014465AOtherINDIANA PROFESSIONAL LICENSING AGENCY