Healthcare Provider Details

I. General information

NPI: 1174287866
Provider Name (Legal Business Name): ASHLEY JANSEN MS, LPC-IT, SAC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2021
Last Update Date: 10/28/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 S PARK ST
MADISON WI
53715-1507
US

IV. Provider business mailing address

1015 GAMMON LN
MADISON WI
53719-2210
US

V. Phone/Fax

Practice location:
  • Phone: 608-417-6000
  • Fax:
Mailing address:
  • Phone: 608-417-8144
  • Fax: 608-417-8145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number777602
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number779929
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: