Provider Demographics
NPI:1336560796
Name:JONGETJES, ELIZABETH ANN (MA, LPC-IT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:JONGETJES
Suffix:
Gender:F
Credentials:MA, LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W6957 SAVANNAH LN
Mailing Address - Street 2:
Mailing Address - City:DELAVAN
Mailing Address - State:WI
Mailing Address - Zip Code:53115-4303
Mailing Address - Country:US
Mailing Address - Phone:262-903-0924
Mailing Address - Fax:
Practice Address - Street 1:12630 W NORTH AVE
Practice Address - Street 2:BUILDING E
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4626
Practice Address - Country:US
Practice Address - Phone:262-785-1008
Practice Address - Fax:262-432-9059
Is Sole Proprietor?:No
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1929-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health