Healthcare Provider Details

I. General information

NPI: 1972915700
Provider Name (Legal Business Name): ADALIA MARITZA JANSEN MAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ADALIA MARITZA JANSEN MAC

II. Dates (important events)

Enumeration Date: 05/28/2014
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 E EVERGREEN DR STE 260
APPLETON WI
54913-7402
US

IV. Provider business mailing address

PO BOX 1555
APPLETON WI
54912-1555
US

V. Phone/Fax

Practice location:
  • Phone: 920-574-5837
  • Fax:
Mailing address:
  • Phone: 920-574-5837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: