Healthcare Provider Details

I. General information

NPI: 1508729294
Provider Name (Legal Business Name): JADE TANJUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N91W17194 APPLETON AVE STE 204
MENOMONEE FALLS WI
53051-2083
US

IV. Provider business mailing address

2454 N 117TH ST
WAUWATOSA WI
53226-1120
US

V. Phone/Fax

Practice location:
  • Phone: 414-502-7780
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5583125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: