Provider Demographics
NPI:1023183134
Name:PEDERSEN, JO ANNE (MSW)
Entity Type:Individual
Prefix:MS
First Name:JO ANNE
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-1806
Mailing Address - Country:US
Mailing Address - Phone:262-352-6047
Mailing Address - Fax:
Practice Address - Street 1:5000 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53295-0001
Practice Address - Country:US
Practice Address - Phone:414-384-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13938101YA0400X
WI68491231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43572000Medicaid