Healthcare Provider Details

I. General information

NPI: 1790270049
Provider Name (Legal Business Name): LEEANN GAUSE JACKSON ATR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
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:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16281-131
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178009221
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number121-36
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7126-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: