Basic Information
| Provider Information | |||||||||
| NPI: | 1235564238 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONDGREN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | KARIN | ||||||||
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| Credential: | MS, LMFT, NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | W175N11120 STONEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530226511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004381772 | ||||||||
| FaxNumber: | 2623455531 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 N RIVERFRONT DR | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560013471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004381772 | ||||||||
| FaxNumber: | 2623455531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2013 | ||||||||
| LastUpdateDate: | 04/11/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 2507 | MN | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 2507 | MN | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | 2507 | MN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1235564238 | 05 | MN | MEDICAID | 2507 | 01 | MN | LICENSE NUMBER | OTHER |