Healthcare Provider Details

I. General information

NPI: 1225648538
Provider Name (Legal Business Name): JENNIFER A VICTOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S CLEVELAND AVE
DEFOREST WI
53532-1618
US

IV. Provider business mailing address

316 MEADOW LN
DEFOREST WI
53532-1426
US

V. Phone/Fax

Practice location:
  • Phone: 608-842-6500
  • Fax:
Mailing address:
  • Phone: 920-838-3609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4893-154
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: