Provider Demographics
NPI:1487864682
Name:EDGE, JENNIFER L (MS ART THERAPY)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:EDGE
Suffix:
Gender:F
Credentials:MS ART THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 PLEASANT OAK DR
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575-3282
Mailing Address - Country:US
Mailing Address - Phone:608-835-5050
Mailing Address - Fax:608-835-5010
Practice Address - Street 1:602 PLEASANT OAK DR
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:WI
Practice Address - Zip Code:53575-3282
Practice Address - Country:US
Practice Address - Phone:608-835-5050
Practice Address - Fax:608-835-5010
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health