Provider Demographics
NPI:1659111813
Name:JEDLICKA, JASMIN
Entity type:Individual
Prefix:
First Name:JASMIN
Middle Name:
Last Name:JEDLICKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 E MEADOW GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-4504
Mailing Address - Country:US
Mailing Address - Phone:920-470-1167
Mailing Address - Fax:
Practice Address - Street 1:1025 E MEADOW GROVE BLVD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-4504
Practice Address - Country:US
Practice Address - Phone:920-470-1167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-27
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI135110-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker