Provider Demographics
NPI:1730227885
Name:WOLLENZIEN-DANIELS, JILL M (PHD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:M
Last Name:WOLLENZIEN-DANIELS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:DANIELS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:2290 RICKIE DR
Mailing Address - Street 2:
Mailing Address - City:MOSINEE
Mailing Address - State:WI
Mailing Address - Zip Code:54455-8848
Mailing Address - Country:US
Mailing Address - Phone:715-298-2104
Mailing Address - Fax:
Practice Address - Street 1:2290 RICKIE DR
Practice Address - Street 2:
Practice Address - City:MOSINEE
Practice Address - State:WI
Practice Address - Zip Code:54455-8848
Practice Address - Country:US
Practice Address - Phone:715-298-2104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2273-057103TA0400X, 103TA0700X, 103TB0200X, 103TC0700X, 103TC2200X, 103TF0200X, 103TM1800X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39274400Medicaid
WI39274400Medicaid