Provider Demographics
NPI:1790250736
Name:KORYCANEK, JENNIFER PAIGE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PAIGE
Last Name:KORYCANEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:879 CRESCENT LN
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-2641
Mailing Address - Country:US
Mailing Address - Phone:773-332-6212
Mailing Address - Fax:
Practice Address - Street 1:W156N8327 PILGRIM RD STE 302
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-3776
Practice Address - Country:US
Practice Address - Phone:262-975-0012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8253.1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical