Basic Information
| Provider Information | |||||||||
| NPI: | 1508876897 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MARIE | ||||||||
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| OtherLastName: | HANSON | ||||||||
| OtherFirstName: | JENNA | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9000 W WISCONSIN AVE # MS 958 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142667451 | ||||||||
| FaxNumber: | 4142666238 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 S CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | MARSHFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153872729 | ||||||||
| FaxNumber: | 7153874526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 08/01/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 126586-121 | WI | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | 7581-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.