Healthcare Provider Details

I. General information

NPI: 1063311371
Provider Name (Legal Business Name): SJT VENTURES WI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2026
Last Update Date: 11/03/2026
Certification Date: 11/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 E ENTERPRISE AVE STE 333
APPLETON WI
54913-7889
US

IV. Provider business mailing address

17595 HARVARD AVE STE C
IRVINE CA
92614-8522
US

V. Phone/Fax

Practice location:
  • Phone: 949-688-3903
  • Fax:
Mailing address:
  • Phone: 949-688-3903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SANJAI THANKACHEN
Title or Position: PRESIDENT
Credential: MD
Phone: 949-688-3903