Provider Demographics
NPI:1538846381
Name:ANDERSON, JAZETTE
Entity type:Individual
Prefix:
First Name:JAZETTE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 752123
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77275-2123
Mailing Address - Country:US
Mailing Address - Phone:312-476-9064
Mailing Address - Fax:312-476-9064
Practice Address - Street 1:2810 CROSSROADS DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-7942
Practice Address - Country:US
Practice Address - Phone:312-476-9064
Practice Address - Fax:312-900-8230
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI133051-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker