Healthcare Provider Details

I. General information

NPI: 1235448093
Provider Name (Legal Business Name): JENNIE LEE WORECK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIE LEE KIRSLING CAPSW

II. Dates (important events)

Enumeration Date: 09/28/2010
Last Update Date: 11/22/2022
Certification Date: 11/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 TRI PARK WAY
APPLETON WI
54914-6430
US

IV. Provider business mailing address

14 TRI PARK WAY
APPLETON WI
54914-6430
US

V. Phone/Fax

Practice location:
  • Phone: 920-831-0070
  • Fax:
Mailing address:
  • Phone: 920-831-0070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10091-123
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: