Healthcare Provider Details

I. General information

NPI: 1326489154
Provider Name (Legal Business Name): PARADIGM ENRICHMENT SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2013
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4222 W CAPITOL DR
MILWAUKEE WI
53216-2500
US

IV. Provider business mailing address

6110 W CAPITOL DR
MILWAUKEE WI
53216-2120
US

V. Phone/Fax

Practice location:
  • Phone: 414-393-0295
  • Fax: 414-393-1155
Mailing address:
  • Phone: 414-393-0295
  • Fax: 414-393-1155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number2990
License Number StateWI

VIII. Authorized Official

Name: MR. FREDERICK GEORGE JACKSON II
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 414-393-0295