Basic Information
| Provider Information | |||||||||
| NPI: | 1245967967 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IPSARIDES | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | DNP, PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 861 BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | CEDARBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530129212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147508835 | ||||||||
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| Practice Location | |||||||||
| Address1: | W129N7055 NORTHFIELD DR | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530510538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622535400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2022 | ||||||||
| LastUpdateDate: | 08/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 251824 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 163W00000X | 251824 | WI | Y | Nursing Service Providers | Registered Nurse |
No ID Information.