Provider Demographics
NPI:1104962380
Name:WILLIQUETTE, JANE A (CADCIII,CCSII)
Entity type:Individual
Prefix:MRS
First Name:JANE
Middle Name:A
Last Name:WILLIQUETTE
Suffix:
Gender:F
Credentials:CADCIII,CCSII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 VIOLA AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-2258
Mailing Address - Country:US
Mailing Address - Phone:920-231-1104
Mailing Address - Fax:
Practice Address - Street 1:915 VIOLA AVE
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901
Practice Address - Country:US
Practice Address - Phone:920-231-1104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI#1421261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder