Provider Demographics
NPI:1942722061
Name:SWANSON, JENNIFER L (EDD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:SWANSON
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 COUNTRYSIDE LN
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5458
Mailing Address - Country:US
Mailing Address - Phone:206-473-2228
Mailing Address - Fax:
Practice Address - Street 1:521 WESTOVER ST
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3776
Practice Address - Country:US
Practice Address - Phone:262-695-8857
Practice Address - Fax:262-695-8879
Is Sole Proprietor?:No
Enumeration Date:2017-07-11
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6562-125101YP2500X
WI3634-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional