Healthcare Provider Details

I. General information

NPI: 1629884739
Provider Name (Legal Business Name): AMANDA JAEGER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMANDA JANE WOLDT

II. Dates (important events)

Enumeration Date: 12/04/2024
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 44
GREEN BAY WI
54305-0044
US

IV. Provider business mailing address

PO BOX 44
GREEN BAY WI
54305-0044
US

V. Phone/Fax

Practice location:
  • Phone: 920-200-6488
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13085-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: