Provider Demographics
NPI:1336951771
Name:VICKERS, JENNIFER R
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:VICKERS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:R
Other - Last Name:FRIES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1685 DRUM CORPS DR APT 5
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1368
Mailing Address - Country:US
Mailing Address - Phone:920-213-3880
Mailing Address - Fax:
Practice Address - Street 1:145 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-3075
Practice Address - Country:US
Practice Address - Phone:920-725-1230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-23
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8240226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional