Provider Demographics
NPI:1174739098
Name:HOLLIS, JENNY BELLE (LICSW)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:BELLE
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 93
Mailing Address - Street 2:
Mailing Address - City:REDLAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671-0093
Mailing Address - Country:US
Mailing Address - Phone:218-679-3316
Mailing Address - Fax:
Practice Address - Street 1:24760 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671
Practice Address - Country:US
Practice Address - Phone:218-679-3316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN025721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical