Healthcare Provider Details

I. General information

NPI: 1346769759
Provider Name (Legal Business Name): AJENG JUWITA PUSPITASARI PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2017
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2153 N DR MARTIN LUTHER KING DR STE 2500
MILWAUKEE WI
53212-3101
US

IV. Provider business mailing address

2153 N DR MARTIN LUTHER KING DR STE 2500
MILWAUKEE WI
53212-3101
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-7276
  • Fax: 414-955-0146
Mailing address:
  • Phone: 414-955-7276
  • Fax: 414-955-0146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5074-057
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP6254
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: