Provider Demographics
NPI:1265023352
Name:KLINGBERG, JANE EMILY (COUNSELOR)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:EMILY
Last Name:KLINGBERG
Suffix:
Gender:
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5756 N YOSEMITE LN
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-2734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1620 S LAWE ST STE 1
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-2419
Practice Address - Country:US
Practice Address - Phone:920-284-9676
Practice Address - Fax:920-481-3121
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11161-125101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180015956OtherSTATE OF ILLINOIS INDEPENDENT COUNSELOR LICENSE (LCPC)
WI1265023352Medicaid
IL178000697OtherILLINOIS COUNSELOR LICENSE NUMBER
WI11161-125OtherWISCONSIN INDEPENDENT COUNSELOR LICENSE (LPC)