Provider Demographics
NPI:1013375419
Name:DUDEK, JENNIFER MARIE (LPCIT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:DUDEK
Suffix:
Gender:F
Credentials:LPCIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N5367 MAYFLOWER RD
Mailing Address - Street 2:
Mailing Address - City:SHIOCTON
Mailing Address - State:WI
Mailing Address - Zip Code:54170-8934
Mailing Address - Country:US
Mailing Address - Phone:920-986-3003
Mailing Address - Fax:920-986-3004
Practice Address - Street 1:N5367 MAYFLOWER RD
Practice Address - Street 2:
Practice Address - City:SHIOCTON
Practice Address - State:WI
Practice Address - Zip Code:54170-8934
Practice Address - Country:US
Practice Address - Phone:920-986-3003
Practice Address - Fax:920-986-3004
Is Sole Proprietor?:No
Enumeration Date:2016-02-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2882-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health