Healthcare Provider Details

I. General information

NPI: 1932887619
Provider Name (Legal Business Name): JACLYNN MARY FRIESEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 05/31/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 ENTERPRISE LN STE 301
MADISON WI
53719-1193
US

IV. Provider business mailing address

1270 OKEEFFE AVE APT 220
SUN PRAIRIE WI
53590-4235
US

V. Phone/Fax

Practice location:
  • Phone: 608-828-3636
  • Fax:
Mailing address:
  • Phone: 507-210-7716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1054-228
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: