Provider Demographics
NPI:1831560259
Name:JENNESS, LYNNETTE KAY (SAC-IT)
Entity type:Individual
Prefix:
First Name:LYNNETTE
Middle Name:KAY
Last Name:JENNESS
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 W 2ND ST N
Mailing Address - Street 2:
Mailing Address - City:LADYSMITH
Mailing Address - State:WI
Mailing Address - Zip Code:54848-1338
Mailing Address - Country:US
Mailing Address - Phone:715-532-9771
Mailing Address - Fax:715-532-9774
Practice Address - Street 1:108 W 2ND ST N
Practice Address - Street 2:
Practice Address - City:LADYSMITH
Practice Address - State:WI
Practice Address - Zip Code:54848-1338
Practice Address - Country:US
Practice Address - Phone:715-532-9771
Practice Address - Fax:715-532-9774
Is Sole Proprietor?:No
Enumeration Date:2015-10-12
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17587101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)