Provider Demographics
NPI:1689789638
Name:GOETTEN, M JAN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:M
Middle Name:JAN
Last Name:GOETTEN
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 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:1220 DEWEY AVE
Practice Address - Street 2:DEWEY CENTER
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213
Practice Address - Country:US
Practice Address - Phone:414-454-6707
Practice Address - Fax:414-454-6747
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6944-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39368300Medicaid