Healthcare Provider Details

I. General information

NPI: 1942467220
Provider Name (Legal Business Name): JILL L KREJCIE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 W MAIN AVE STE 201
DE PERE WI
54115-1695
US

IV. Provider business mailing address

1210 FOURIER DR STE 100
MADISON WI
53717-1969
US

V. Phone/Fax

Practice location:
  • Phone: 920-338-1610
  • Fax: 920-338-1616
Mailing address:
  • Phone: 608-662-9327
  • Fax: 608-662-9041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number796-124
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: