Provider Demographics
NPI:1326416355
Name:JORGENSEN, DONNA (LPC, CSAC)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5015 31ST ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-7320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 57TH ST UNIT I
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-4062
Practice Address - Country:US
Practice Address - Phone:262-354-7159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-08
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16217-132101YA0400X
WI705-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1326416355Medicaid
WI1326416355OtherCCHP. BCBS, UNITED HEALTHCARE