Provider Demographics
NPI:1487818068
Name:BOSCH, JENNIFER M
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:BOSCH
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:N19W24400 RIVERWOOD DR
Mailing Address - Street 2:STE 350, PMB 467
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188
Mailing Address - Country:US
Mailing Address - Phone:414-916-0555
Mailing Address - Fax:
Practice Address - Street 1:240 N MILWAUKEE ST # 202
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-5830
Practice Address - Country:US
Practice Address - Phone:262-646-8288
Practice Address - Fax:262-646-8255
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7596-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43740800Medicaid