Provider Demographics
NPI:1609249929
Name:BROMLEY, JENNIFER SUZANNE (LICSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUZANNE
Last Name:BROMLEY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 THIELEN DR
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376-9613
Mailing Address - Country:US
Mailing Address - Phone:763-515-4563
Mailing Address - Fax:763-497-0552
Practice Address - Street 1:703 THIELEN DR
Practice Address - Street 2:
Practice Address - City:SAINT MICHAEL
Practice Address - State:MN
Practice Address - Zip Code:55376-9613
Practice Address - Country:US
Practice Address - Phone:763-515-4563
Practice Address - Fax:763-497-0552
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN248741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical