Provider Demographics
NPI:1801199302
Name:LAKE, JENNIFER MARIE (MA, LMFT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:LAKE
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:KETZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LMFT
Mailing Address - Street 1:8119 50TH AVE. N.
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428
Mailing Address - Country:US
Mailing Address - Phone:612-799-8258
Mailing Address - Fax:
Practice Address - Street 1:2233 N. HAMLINE AVE., SUITE 411
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:612-799-8258
Practice Address - Fax:651-330-8718
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-06
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
MN2425106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist