Provider Demographics
NPI:1760149553
Name:DOUGLAS, JENNIFER ANN (TREATMENT TRAINEE 1)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:TREATMENT TRAINEE 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 HARTBROOK DR STE 202
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-1415
Mailing Address - Country:US
Mailing Address - Phone:262-361-4275
Mailing Address - Fax:
Practice Address - Street 1:510 HARTBROOK DR STE 202
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-1415
Practice Address - Country:US
Practice Address - Phone:262-361-4275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1528364825101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI472230426Medicaid