Provider Demographics
NPI:1568102788
Name:KAVANAGH, JENNA L (LADC)
Entity Type:Individual
Prefix:MS
First Name:JENNA
Middle Name:L
Last Name:KAVANAGH
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 N SHORE DR APT 3
Mailing Address - Street 2:
Mailing Address - City:BATTLE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56515-4070
Mailing Address - Country:US
Mailing Address - Phone:701-261-7911
Mailing Address - Fax:
Practice Address - Street 1:305 30TH AVE W
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3429
Practice Address - Country:US
Practice Address - Phone:320-460-8028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305726101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)