Healthcare Provider Details

I. General information

NPI: 1215308150
Provider Name (Legal Business Name): JESSICA MARIE SHIPMAN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 COUNTY ROAD NN
ELKHORN WI
53121-4454
US

IV. Provider business mailing address

PO BOX 1005
ELKHORN WI
53121-1005
US

V. Phone/Fax

Practice location:
  • Phone: 262-741-3200
  • Fax: 262-741-3217
Mailing address:
  • Phone: 262-741-3200
  • Fax: 262-741-3217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number4962-125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4962-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: