Provider Demographics
NPI:1194569384
Name:BLAHA, JOLENE ROSE (APSW)
Entity type:Individual
Prefix:
First Name:JOLENE
Middle Name:ROSE
Last Name:BLAHA
Suffix:
Gender:F
Credentials:APSW
Other - Prefix:
Other - First Name:JOLENE
Other - Middle Name:ROSE
Other - Last Name:OBRION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APSW
Mailing Address - Street 1:452 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:53932-9527
Mailing Address - Country:US
Mailing Address - Phone:920-350-2866
Mailing Address - Fax:
Practice Address - Street 1:199 COUNTY ROAD DF
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:WI
Practice Address - Zip Code:53039-9512
Practice Address - Country:US
Practice Address - Phone:920-386-4094
Practice Address - Fax:920-386-4564
Is Sole Proprietor?:No
Enumeration Date:2024-06-21
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI103481-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker