Provider Demographics
NPI:1578288403
Name:CONNOLLY, JENNIFER (LADC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CONNOLLY
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 1:11452 KENYON CT NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-5480
Mailing Address - Country:US
Mailing Address - Phone:612-272-7953
Mailing Address - Fax:
Practice Address - Street 1:11660 ROUND LAKE BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2638
Practice Address - Country:US
Practice Address - Phone:763-767-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305835101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)