Provider Demographics
NPI:1013124239
Name:BLEAK, JENNIFER (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BLEAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BELOIT HEALTH SYSTEM COUNSELLING CARE CENTER
Mailing Address - Street 2:1969 W. HART RD
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-2230
Mailing Address - Country:US
Mailing Address - Phone:608-364-5689
Mailing Address - Fax:608-364-5525
Practice Address - Street 1:BELOIT HEALTH SYSTEM COUNSELLING CARE CENTER
Practice Address - Street 2:1969 W. HART RD
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2230
Practice Address - Country:US
Practice Address - Phone:608-364-5689
Practice Address - Fax:608-364-5525
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50247-202084P0800X
WI036-0837572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100002708Medicaid