Provider Demographics
NPI:1801368493
Name:DALGORD, JENNA MAE (MSW, APSW, SAC-IT)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MAE
Last Name:DALGORD
Suffix:
Gender:F
Credentials:MSW, APSW, SAC-IT
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:M
Other - Last Name:SIDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 22308
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2308
Mailing Address - Country:US
Mailing Address - Phone:920-436-6800
Mailing Address - Fax:920-437-3540
Practice Address - Street 1:300 CROOKS ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4527
Practice Address - Country:US
Practice Address - Phone:920-436-6800
Practice Address - Fax:920-437-3540
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20765101YA0400X
WI1350921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI135092OtherSTATE LICENSE
WI1801368493Medicaid
WI20765OtherSTATE LICENSE SAC-IT