MEDICARE: ELIZABETH ANN JONGETJES M.A., LPC-IT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	1929-226	WI

General Provider Information

NPI Number	:	1336560796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH ANN JONGETJES M.A., LPC-IT

Provider Business Mailing Address
First Line	:	W6957 SAVANNAH LN
Second Line	:
City	:	DELAVAN
State	:	WI
Zip	:	53115-4303
Country	:	US
Telephone Number	:	262-903-0924
Fax Number	:

Provider Business Practice Location Address
First Line	:	12630 W NORTH AVE
Second Line	:	BUILDING E
City	:	BROOKFIELD
State	:	WI
Zip	:	53005-4626
Country	:	US
Telephone Number	:	262-785-1008
Fax Number	:	262-432-9059

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2014
Last Update Date	:	01/02/2014

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