Healthcare Provider Details

I. General information

NPI: 1164148847
Provider Name (Legal Business Name): JB BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2022
Last Update Date: 12/24/2022
Certification Date: 12/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N BROADWAY STE 110
DE PERE WI
54115-2571
US

IV. Provider business mailing address

301 N BROADWAY STE 110
DE PERE WI
54115-2571
US

V. Phone/Fax

Practice location:
  • Phone: 920-425-4900
  • Fax: 920-425-4200
Mailing address:
  • Phone: 920-425-4900
  • Fax: 920-425-4200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JUSTINE M. GARBACIAK
Title or Position: OWNER/CLINICAL DIRECTOR
Credential: MS, LPC
Phone: 920-639-1032