Provider Demographics
NPI:1295014199
Name:JENSEMA, ELIZABETH A (LCSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:JENSEMA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:A
Other - Last Name:FICHTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:W2228 KOENE CT
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53085-2719
Mailing Address - Country:US
Mailing Address - Phone:920-980-2183
Mailing Address - Fax:
Practice Address - Street 1:W2228 KOENE CT
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN FALLS
Practice Address - State:WI
Practice Address - Zip Code:53085-2719
Practice Address - Country:US
Practice Address - Phone:920-980-2183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI85221231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1295014199Medicaid
1295014199OtherBCBS MN
SDS105181Medicare PIN