Provider Demographics
NPI:1730203746
Name:NOVAK, JENNIFER ANNE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:NOVAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10333 HIGHWAY 25 NE
Mailing Address - Street 2:
Mailing Address - City:FOLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56329-8402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2700 1ST ST N
Practice Address - Street 2:SUITE 103
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4256
Practice Address - Country:US
Practice Address - Phone:320-259-6022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172981101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health