Provider Demographics
NPI:1578668166
Name:JENDRO, JENNIFER LEE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LEE
Last Name:JENDRO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4733 14TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3646
Mailing Address - Country:US
Mailing Address - Phone:612-483-5183
Mailing Address - Fax:
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 229N
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1052
Practice Address - Country:US
Practice Address - Phone:612-483-5183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN166101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN986450400Medicaid