Provider Demographics
NPI:1124173133
Name:HERZOG, JEANNE MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:JEANNE
Middle Name:MARIE
Last Name:HERZOG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2912 DEVONSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1368
Mailing Address - Country:US
Mailing Address - Phone:414-258-8488
Mailing Address - Fax:262-547-1978
Practice Address - Street 1:890 ELM GROVE RD STE 214
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2528
Practice Address - Country:US
Practice Address - Phone:414-258-8488
Practice Address - Fax:262-547-1978
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2176-57103TC0700X
WI2176057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical