Basic Information
| Provider Information | |||||||||
| NPI: | 1861805822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SNOOK | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | LOU | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | CANVAS HEALTH | ||||||||
| Address2: | 8451 E POINT DOUGLAS RD 5 | ||||||||
| City: | COTTAGE GROVE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512558558 | ||||||||
| FaxNumber: | 6514585632 | ||||||||
| Practice Location | |||||||||
| Address1: | 840 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PERHAM | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565731934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183466100 | ||||||||
| FaxNumber: | 2183466112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2014 | ||||||||
| LastUpdateDate: | 05/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 303398 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 303398 | 01 | MN | LADC LICENSE | OTHER |