Provider Demographics
NPI:1598408171
Name:MIZELLE, JENNIFER NOE (LPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NOE
Last Name:MIZELLE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5250 E TERRACE DR STE 114
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718-8345
Mailing Address - Country:US
Mailing Address - Phone:608-405-5111
Mailing Address - Fax:
Practice Address - Street 1:5250 E TERRACE DR STE 114
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-8345
Practice Address - Country:US
Practice Address - Phone:608-405-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7893-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional