Provider Demographics
NPI:1982966958
Name:MIJAL, JESSICA (PSYD, LP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MIJAL
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 TUMBLEWEED DR
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-1189
Mailing Address - Country:US
Mailing Address - Phone:612-382-7593
Mailing Address - Fax:
Practice Address - Street 1:505 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-2183
Practice Address - Country:US
Practice Address - Phone:608-355-4211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3026-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist