Provider Demographics
NPI:1770265944
Name:JANSEN-KUBICEK, MARY THERESE (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:THERESE
Last Name:JANSEN-KUBICEK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 N 73RD ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2214
Mailing Address - Country:US
Mailing Address - Phone:414-940-5691
Mailing Address - Fax:
Practice Address - Street 1:1751 N 73RD ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-2214
Practice Address - Country:US
Practice Address - Phone:414-940-5691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2521-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty