Provider Demographics
NPI:1326823360
Name:JASPER, ELIZABETH KAY
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:KAY
Last Name:JASPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1038 COUNTY ROAD D W
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55126-3782
Mailing Address - Country:US
Mailing Address - Phone:651-252-7373
Mailing Address - Fax:
Practice Address - Street 1:800 WILSON AVE RM 330
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-2746
Practice Address - Country:US
Practice Address - Phone:715-256-7166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7558-226101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health