1770691164 NPI number — MR. JOHN PETER JENDUSA LCSW

Table of content: MR. JOHN PETER JENDUSA LCSW (NPI 1770691164)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770691164 NPI number — MR. JOHN PETER JENDUSA LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENDUSA
Provider First Name:
JOHN
Provider Middle Name:
PETER
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

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:
1770691164
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5225 NORTH IRONWOOD ROAD
Provider Second Line Business Mailing Address:
102
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-962-9156
Provider Business Mailing Address Fax Number:
414-962-4356

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5225 NORTH IRONWOOD ROAD
Provider Second Line Business Practice Location Address:
102
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-962-9156
Provider Business Practice Location Address Fax Number:
414-962-4356
Provider Enumeration Date:
08/27/2006

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 , with the licence number:  2251-123 , 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: 39237400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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