Provider Demographics
NPI:1346200052
Name:JENKINS, JUDITH ANNE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:ANNE
Last Name:JENKINS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:JUDY
Other - Middle Name:ANNE
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:1045 W GLEN OAKS LN STE 1
Mailing Address - Street 2:DBA MEQUON CLINICAL ASSOCIATES
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3477
Mailing Address - Country:US
Mailing Address - Phone:262-241-7778
Mailing Address - Fax:262-241-8200
Practice Address - Street 1:1045 W GLEN OAKS LN STE 1
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3477
Practice Address - Country:US
Practice Address - Phone:262-241-7778
Practice Address - Fax:262-241-8200
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6589-123104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI68375Medicare PIN
WI84145Medicare PIN
WIP11930Medicare UPIN
WI0239Medicare ID - Type Unspecified