Provider Demographics
NPI:1770691164
Name:JENDUSA, JOHN PETER (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:PETER
Last Name:JENDUSA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5225 NORTH IRONWOOD ROAD
Mailing Address - Street 2:102
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217
Mailing Address - Country:US
Mailing Address - Phone:414-962-9156
Mailing Address - Fax:414-962-4356
Practice Address - Street 1:5225 NORTH IRONWOOD ROAD
Practice Address - Street 2:102
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217
Practice Address - Country:US
Practice Address - Phone:414-962-9156
Practice Address - Fax:414-962-4356
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2251-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39237400Medicaid
WI39237400Medicaid