Provider Demographics
NPI:1194383281
Name:VONFELDT, JENA (LCSW)
Entity Type:Individual
Prefix:
First Name:JENA
Middle Name:
Last Name:VONFELDT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENA
Other - Middle Name:HART
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:N3095 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-7048
Mailing Address - Country:US
Mailing Address - Phone:406-212-3293
Mailing Address - Fax:
Practice Address - Street 1:N3095 LAKE DR
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-7048
Practice Address - Country:US
Practice Address - Phone:406-212-3293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MTBBH-LCSW-LIC-554361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1026117Medicaid