Provider Demographics
NPI:1477219756
Name:JESKE, MANDY R (APSW)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:R
Last Name:JESKE
Suffix:
Gender:F
Credentials:APSW
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:R
Other - Last Name:O'MALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:987 CLAM FALLS DR
Mailing Address - Street 2:
Mailing Address - City:FREDERIC
Mailing Address - State:WI
Mailing Address - Zip Code:54837-4704
Mailing Address - Country:US
Mailing Address - Phone:715-822-0690
Mailing Address - Fax:715-822-0690
Practice Address - Street 1:241 S MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:LUCK
Practice Address - State:WI
Practice Address - Zip Code:54853-7100
Practice Address - Country:US
Practice Address - Phone:715-822-0690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2025-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI132286-121104100000X
WI11519-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker