Provider Demographics
NPI:1831663343
Name:RENNQUIST, JENNIFER T (MSED, LADC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:T
Last Name:RENNQUIST
Suffix:
Gender:F
Credentials:MSED, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5223 GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-1110
Mailing Address - Country:US
Mailing Address - Phone:218-591-5649
Mailing Address - Fax:
Practice Address - Street 1:5223 GLENDALE ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55804-1110
Practice Address - Country:US
Practice Address - Phone:218-591-5649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303519101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)