Basic Information
| Provider Information | |||||||||
| NPI: | 1528467495 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATER | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | SAC-IT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9910 W LAYTON AVE | ||||||||
| Address2: | SUITE #2 | ||||||||
| City: | GREENFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532283363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144274884 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9910 W LAYTON AVE | ||||||||
| Address2: | SUITE #2 | ||||||||
| City: | GREENFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532283363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144274884 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2014 | ||||||||
| LastUpdateDate: | 08/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 17136-130 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.