Provider Demographics
NPI:1992398770
Name:POLK, JENNIFER (MS, LPCC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:POLK
Suffix:
Gender:F
Credentials:MS, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4430 21ST ST SE APT 309
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-6479
Mailing Address - Country:US
Mailing Address - Phone:701-319-0111
Mailing Address - Fax:
Practice Address - Street 1:600 S 2ND ST STE 201
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5729
Practice Address - Country:US
Practice Address - Phone:701-258-3780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-12
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1129-6-1-21A101YP2500X
ND1129-6-1-21-550101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional