Provider Demographics
NPI:1114425303
Name:WHITE, JENNIFER MARY (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARY
Last Name:WHITE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 W WASHINGTON AVE STE 501
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-3007
Mailing Address - Country:US
Mailing Address - Phone:608-280-2095
Mailing Address - Fax:
Practice Address - Street 1:345 W WASHINGTON AVE STE 501
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-3007
Practice Address - Country:US
Practice Address - Phone:608-280-2095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8719-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI8719-123OtherSOCIAL WORK STATE LICENSE