Healthcare Provider Details

I. General information

NPI: 1245846195
Provider Name (Legal Business Name): JANNA NORDEMAN MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 BELLEVUE ST STE 113
GREEN BAY WI
54302-2155
US

IV. Provider business mailing address

1221 BELLEVUE ST STE 113
GREEN BAY WI
54302-2155
US

V. Phone/Fax

Practice location:
  • Phone: 920-482-2932
  • Fax: 800-892-6147
Mailing address:
  • Phone: 920-482-2932
  • Fax: 800-892-6147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number128072
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9702-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: