Basic Information
| Provider Information | |||||||||
| NPI: | 1194272419 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAKEL | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | VIRGINIA ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LCSW, SAC-IT | ||||||||
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| Mailing Information | |||||||||
| Address1: | N6520 LUMBERJACK GUY RD | ||||||||
| Address2: | |||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546155405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152849851 | ||||||||
| FaxNumber: | 7152845150 | ||||||||
| Practice Location | |||||||||
| Address1: | N6520 LUMBERJACK GUY RD | ||||||||
| Address2: | |||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546155405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152849851 | ||||||||
| FaxNumber: | 7152843434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2016 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 9110 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | 18634 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 100060771 | 05 | WI | MEDICAID |