Provider Demographics
NPI:1780700708
Name:HACK, JANNA LYNN (LCSW)
Entity type:Individual
Prefix:MS
First Name:JANNA
Middle Name:LYNN
Last Name:HACK
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 1:302 S. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534
Mailing Address - Country:US
Mailing Address - Phone:608-239-7648
Mailing Address - Fax:
Practice Address - Street 1:302 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534
Practice Address - Country:US
Practice Address - Phone:608-239-7648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7174-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40933900Medicaid