Provider Demographics
NPI:1861805822
Name:SNOOK, JENNY LOU (LADC)
Entity type:Individual
Prefix:MS
First Name:JENNY
Middle Name:LOU
Last Name:SNOOK
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CANVAS HEALTH
Mailing Address - Street 2:8451 E POINT DOUGLAS RD 5
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016
Mailing Address - Country:US
Mailing Address - Phone:651-255-8558
Mailing Address - Fax:651-458-5632
Practice Address - Street 1:840 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-1934
Practice Address - Country:US
Practice Address - Phone:218-346-6100
Practice Address - Fax:218-346-6112
Is Sole Proprietor?:No
Enumeration Date:2014-06-07
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303398101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN303398OtherLADC LICENSE