1750745949 NPI number — MRS. JENNIFER WOLF M.ED., BCBA

Table of content: MRS. JENNIFER WOLF M.ED., BCBA (NPI 1750745949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750745949 NPI number — MRS. JENNIFER WOLF M.ED., BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOLF
Provider First Name:
JENNIFER
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.ED., BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROSKOPF
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
B.A.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1750745949
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N27W23953 PAUL RD
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
PEWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53072-6242
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-347-0701
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N27W23953 PAUL RD
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
PEWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53072-6242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-347-0701
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  143-140 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100051299 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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