=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295899029
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER ANNE CORBETT-WILLING M.ED , LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5407 8TH AVE
-----------------------------------------------------
City | KENOSHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53140-3715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-564-0067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8737 SHADY OAK TRL
-----------------------------------------------------
City | RACINE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53406-3108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-886-5523
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 3680-125
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------