Provider Demographics
NPI:1922294040
Name:DOMBROWSKI, JACQUELINE EDWINA (MSW, LCSW, CMT)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:EDWINA
Last Name:DOMBROWSKI
Suffix:
Gender:F
Credentials:MSW, LCSW, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18705 BROOKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-1029
Mailing Address - Country:US
Mailing Address - Phone:262-781-5333
Mailing Address - Fax:262-781-6603
Practice Address - Street 1:300 COTTONWOOD AVE STE 4
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-2043
Practice Address - Country:US
Practice Address - Phone:414-405-2486
Practice Address - Fax:262-367-3828
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7122-123101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health