=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063226157
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNA NELSON PSY.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2025
-----------------------------------------------------
Last Update Date | 09/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | PO BOX 54
-----------------------------------------------------
City | WINNEBAGO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54985-0054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-220-0313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 54
-----------------------------------------------------
City | WINNEBAGO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54985-0054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-220-0313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 3640-57
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------