Provider Demographics
NPI:1265117261
Name:MALLEY, JENNIFER ANN (MS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:MALLEY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3263 XENIA AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2637
Mailing Address - Country:US
Mailing Address - Phone:701-238-6862
Mailing Address - Fax:
Practice Address - Street 1:3263 XENIA AVE N
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55422-2637
Practice Address - Country:US
Practice Address - Phone:701-238-6862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00391101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional