Basic Information
Provider Information | |||||||||
NPI: | 1457710204 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PALMBACH | ||||||||
FirstName: | JILLIAN | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | 17632-130 | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2811 W GLENPARK DR | ||||||||
Address2: |   | ||||||||
City: | APPLETON | ||||||||
State: | WI | ||||||||
PostalCode: | 549141571 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9205386261 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3301 N BALLARD RD | ||||||||
Address2: | STE B | ||||||||
City: | APPLETON | ||||||||
State: | WI | ||||||||
PostalCode: | 549118928 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9207334443 | ||||||||
FaxNumber: | 9207334796 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2016 | ||||||||
LastUpdateDate: | 02/22/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 17632-130 | WI | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.