1588759724 NPI number — MS. JANE M PETERSEN LCSW

Table of content: MS. JANE M PETERSEN LCSW (NPI 1588759724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588759724 NPI number — MS. JANE M PETERSEN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSEN
Provider First Name:
JANE
Provider Middle Name:
M
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588759724
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6502 GRAND TETON PLAZA
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53719-1047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-827-7220
Provider Business Practice Location Address Fax Number:
608-827-7223
Provider Enumeration Date:
10/04/2006

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: 1041C0700X , 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: 39668600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com