Basic Information
| Provider Information | |||||||||
| NPI: | 1417353798 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENNELLE | ||||||||
| FirstName: | LINDSEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | LISW, IAADC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOFFAT | ||||||||
| OtherFirstName: | LINDSEY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LISW, IAADC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9943 HICKMAN RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | URBANDALE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503225304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152481447 | ||||||||
| FaxNumber: | 5152481440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1202 DUFF AVE | ||||||||
| Address2: | |||||||||
| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500105408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152320628 | ||||||||
| FaxNumber: | 5152320727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2014 | ||||||||
| LastUpdateDate: | 12/01/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 008068 | IA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.