Provider Demographics
NPI:1477858058
Name:HAVILAND, JENNIE RAE (MS LMFT)
Entity Type:Individual
Prefix:MS
First Name:JENNIE
Middle Name:RAE
Last Name:HAVILAND
Suffix:
Gender:F
Credentials:MS LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 US HIGHWAY 12 E STE 225
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-3045
Mailing Address - Country:US
Mailing Address - Phone:715-231-2771
Mailing Address - Fax:715-232-5987
Practice Address - Street 1:3001 US HIGHWAY 12 E STE 225
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-3045
Practice Address - Country:US
Practice Address - Phone:715-231-2771
Practice Address - Fax:715-232-5987
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-13
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1074-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100072751Medicaid
14135702OtherCAQH