Provider Demographics
NPI:1245191592
Name:CARLSON, JENNIFER MARIE (LPC-IT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4146 CHEROKEE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-3031
Mailing Address - Country:US
Mailing Address - Phone:917-386-7437
Mailing Address - Fax:
Practice Address - Street 1:1716 FORDEM AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-4604
Practice Address - Country:US
Practice Address - Phone:608-221-3511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-18
Last Update Date:2025-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor