Provider Demographics
NPI:1760598221
Name:PFANNERSTILL PURNELL, JENNIFER R (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:PFANNERSTILL PURNELL
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 1:9000 W WISCONSIN AVE # MS 958
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-7615
Mailing Address - Fax:414-266-6238
Practice Address - Street 1:1655 W MEQUON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3254
Practice Address - Country:US
Practice Address - Phone:414-266-3339
Practice Address - Fax:262-240-9745
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6895-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1760598221Medicaid
WI40964300Medicaid