Healthcare Provider Details

I. General information

NPI: 1841648839
Provider Name (Legal Business Name): JENNIFER LEA BURKEL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER L COUILLARD

II. Dates (important events)

Enumeration Date: 05/31/2016
Last Update Date: 12/21/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 W WASHINGTON AVE STE 630
MADISON WI
53703-2758
US

IV. Provider business mailing address

122 WEST WASHIGHTON AVENUE, SUITE 630
MADISON WI
53703
US

V. Phone/Fax

Practice location:
  • Phone: 608-424-8411
  • Fax:
Mailing address:
  • Phone: 608-424-8411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number129635-121
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9360-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: