Provider Demographics
NPI:1477219756
Name:JESKE, MANDY R (APSW)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:R
Last Name:JESKE
Suffix:
Gender:F
Credentials:APSW
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:R
Other - Last Name:O'MALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:SIREN
Mailing Address - State:WI
Mailing Address - Zip Code:54872-0309
Mailing Address - Country:US
Mailing Address - Phone:715-349-7069
Mailing Address - Fax:888-625-8634
Practice Address - Street 1:203 UNITED WAY
Practice Address - Street 2:
Practice Address - City:FREDERIC
Practice Address - State:WI
Practice Address - Zip Code:54837-8938
Practice Address - Country:US
Practice Address - Phone:715-349-7069
Practice Address - Fax:888-625-8634
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI132286-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker