Provider Demographics
NPI:1689301863
Name:GRANTMAN, JESSICA MAE (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MAE
Last Name:GRANTMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 NEW TOWN DR APT 310
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-7082
Mailing Address - Country:US
Mailing Address - Phone:608-729-8696
Mailing Address - Fax:608-403-3464
Practice Address - Street 1:122 E OLIN AVE STE 220
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-1482
Practice Address - Country:US
Practice Address - Phone:608-729-8696
Practice Address - Fax:608-403-3464
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-06
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9311-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical