Provider Demographics
NPI:1235957523
Name:CARRIVEAU, JENNA KAY
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:KAY
Last Name:CARRIVEAU
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 1:709 15TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2544
Mailing Address - Country:US
Mailing Address - Phone:701-866-3609
Mailing Address - Fax:
Practice Address - Street 1:1530 1ST AVE N STE 150
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-0002
Practice Address - Country:US
Practice Address - Phone:218-228-3296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician