Healthcare Provider Details

I. General information

NPI: 1578498143
Provider Name (Legal Business Name): NATHANIEL C JAFFEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E BURLEIGH ST
MILWAUKEE WI
53212-2119
US

IV. Provider business mailing address

W175N11120 STONEWOOD DR
GERMANTOWN WI
53022-4799
US

V. Phone/Fax

Practice location:
  • Phone: 800-438-1772
  • Fax:
Mailing address:
  • Phone: 800-438-1772
  • Fax: 262-345-5562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12513
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: