Provider Demographics
NPI:1659452571
Name:JORGENSON, HOLLY (LCSW, LPC)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:JORGENSON
Suffix:
Gender:F
Credentials:LCSW, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 WISCONSIN AVE.
Mailing Address - Street 2:401 WISCONSIN AVE.
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-1465
Mailing Address - Country:US
Mailing Address - Phone:608-256-5115
Mailing Address - Fax:608-256-5116
Practice Address - Street 1:401 WISCONSIN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-1487
Practice Address - Country:US
Practice Address - Phone:608-256-5115
Practice Address - Fax:608-256-5116
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2069-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40909400Medicaid
WI40909400Medicaid