Healthcare Provider Details

I. General information

NPI: 1346200052
Provider Name (Legal Business Name): JUDITH ANNE JENKINS L.C.S.W
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JUDY ANNE JENKINS LCSW

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 W GLEN OAKS LN STE 1
MEQUON WI
53092-3477
US

IV. Provider business mailing address

1045 W GLEN OAKS LN STE 1 DBA MEQUON CLINICAL ASSOCIATES
MEQUON WI
53092-3477
US

V. Phone/Fax

Practice location:
  • Phone: 262-241-7778
  • Fax: 262-241-8200
Mailing address:
  • Phone: 262-241-7778
  • Fax: 262-241-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6589-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: