Provider Demographics
NPI:1699064808
Name:CHELLEVOLD, JENNIFER L (MS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:CHELLEVOLD
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 S RIVER ST
Mailing Address - Street 2:254
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-3860
Mailing Address - Country:US
Mailing Address - Phone:608-755-5260
Mailing Address - Fax:608-755-5267
Practice Address - Street 1:17 S RIVER ST
Practice Address - Street 2:254
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-3860
Practice Address - Country:US
Practice Address - Phone:608-755-5260
Practice Address - Fax:608-755-5267
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI637-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health