Provider Demographics
NPI:1598087058
Name:O'DONNELL KJOS, LISA (MSE, EDS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:O'DONNELL KJOS
Suffix:
Gender:F
Credentials:MSE, EDS
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:KJOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:516 FORD DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:BARNEVELD
Mailing Address - State:WI
Mailing Address - Zip Code:53507-9435
Mailing Address - Country:US
Mailing Address - Phone:608-346-5234
Mailing Address - Fax:
Practice Address - Street 1:101 E FOUNTAIN ST # 2
Practice Address - Street 2:
Practice Address - City:DODGEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53533-1749
Practice Address - Country:US
Practice Address - Phone:608-835-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-24
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI62616466103TS0200X
WI7103-226101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool