Provider Demographics
NPI:1750438651
Name:WEIDNER, JENNIFER LEIGH (LCSW)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LEIGH
Last Name:WEIDNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:LEIGH
Other - Last Name:FRUIN, HOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:74 ECLIPSE CTR
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-3550
Mailing Address - Country:US
Mailing Address - Phone:608-361-0311
Mailing Address - Fax:
Practice Address - Street 1:74 ECLIPSE CTR
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-3550
Practice Address - Country:US
Practice Address - Phone:608-361-0311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6135-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6135-123OtherLCSW
WI43574600Medicaid