Provider Demographics
NPI:1154486876
Name:EVANCY, JENNIFER L (APSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:EVANCY
Suffix:
Gender:F
Credentials:APSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 GOOLD ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-4567
Mailing Address - Country:US
Mailing Address - Phone:262-638-2000
Mailing Address - Fax:262-638-2006
Practice Address - Street 1:800 GOOLD ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-4567
Practice Address - Country:US
Practice Address - Phone:262-638-2000
Practice Address - Fax:262-638-2006
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8650-1231041C0700X
WI17601-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391442732Medicaid