Healthcare Provider Details

I. General information

NPI: 1275261935
Provider Name (Legal Business Name): MARK JONATHAN OLDENBURG LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2022
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4509 ARTHUR RD
SLINGER WI
53086-9603
US

IV. Provider business mailing address

900 FOX CREEK DR APT 5
WATERTOWN WI
53098-1314
US

V. Phone/Fax

Practice location:
  • Phone: 414-966-7136
  • Fax:
Mailing address:
  • Phone: 262-366-7948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12445
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: