Provider Demographics
NPI:1336818616
Name:WALSTEAD, JENNA L (SAC-IT)
Entity Type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:L
Last Name:WALSTEAD
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 N PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:WI
Mailing Address - Zip Code:53523-9404
Mailing Address - Country:US
Mailing Address - Phone:608-843-7966
Mailing Address - Fax:
Practice Address - Street 1:2914 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-4047
Practice Address - Country:US
Practice Address - Phone:608-223-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19298-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)