Provider Demographics
NPI:1013380914
Name:DIAMOND, JENNIFER (MSW, APSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DIAMOND
Suffix:
Gender:F
Credentials:MSW, APSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53508-9188
Mailing Address - Country:US
Mailing Address - Phone:608-424-9100
Mailing Address - Fax:608-424-9099
Practice Address - Street 1:1148 SADDLE RDG
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9799
Practice Address - Country:US
Practice Address - Phone:608-669-3266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI127790-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker