Provider Demographics
NPI:1255810115
Name:TENNESSEN, JENNIFER LYNN (SAC-IT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:TENNESSEN
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:N472 KILSDONK CT
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-8726
Mailing Address - Country:US
Mailing Address - Phone:920-851-4468
Mailing Address - Fax:
Practice Address - Street 1:3301 N BALLARD RD STE B
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-9002
Practice Address - Country:US
Practice Address - Phone:920-851-4468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-11
Last Update Date:2018-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18280-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)