Provider Demographics
NPI:1922190768
Name:BURELBACH, JENNIFER LYNN (MSSA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:BURELBACH
Suffix:
Gender:F
Credentials:MSSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 EAST AVE S STE 101
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-8282
Mailing Address - Country:US
Mailing Address - Phone:608-397-8727
Mailing Address - Fax:
Practice Address - Street 1:2920 EAST AVE S STE 101
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-8282
Practice Address - Country:US
Practice Address - Phone:608-397-8727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI68901231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40939800Medicaid
WI376343OtherTRICARE CHAMPUS
WI40939800Medicaid