MEDICARE: MS. JANE M PETERSEN LCSW

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	1041C0700X	Clinical Social Worker		WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588759724
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JANE M PETERSEN LCSW

Provider Business Mailing Address
First Line	:	5 HAVERHILL CIRCLE
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53717-1026
Country	:	US
Telephone Number	:	608-836-0611
Fax Number	:

Provider Business Practice Location Address
First Line	:	6502 GRAND TETON PLAZA
Second Line	:	SUITE 203
City	:	MADISON
State	:	WI
Zip	:	53719-1047
Country	:	US
Telephone Number	:	608-827-7220
Fax Number	:	608-827-7223

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

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	07/08/2007

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