Provider Demographics
NPI:1316294283
Name:JANDOUREK, MARY FRANCES (CSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:FRANCES
Last Name:JANDOUREK
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4435 W LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-4065
Mailing Address - Country:US
Mailing Address - Phone:920-750-5553
Mailing Address - Fax:
Practice Address - Street 1:4435 W LAWRENCE ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-4065
Practice Address - Country:US
Practice Address - Phone:920-750-5553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8100-120104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker