Healthcare Provider Details

I. General information

NPI: 1982966958
Provider Name (Legal Business Name): JESSICA MIJAL PSY.D, L.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 BROADWAY ST
BARABOO WI
53913-2183
US

IV. Provider business mailing address

2005 TUMBLEWEED DR
PRAIRIE DU SAC WI
53578-1189
US

V. Phone/Fax

Practice location:
  • Phone: 608-355-4211
  • Fax:
Mailing address:
  • Phone: 612-382-7593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3026-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: