Healthcare Provider Details

I. General information

NPI: 1396480158
Provider Name (Legal Business Name): JASMINE WEARY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5322 N DEXTER AVE
MILWAUKEE WI
53209-5040
US

IV. Provider business mailing address

5322 N DEXTER AVE
MILWAUKEE WI
53209-5040
US

V. Phone/Fax

Practice location:
  • Phone: 414-400-3199
  • Fax:
Mailing address:
  • Phone: 414-400-3199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: