Healthcare Provider Details

I. General information

NPI: 1073234191
Provider Name (Legal Business Name): JEESENIA ZAVALA QTT-LPC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2906 S 20TH ST
MILWAUKEE WI
53215-3732
US

IV. Provider business mailing address

PO BOX 778789
CHICAGO IL
60677-8789
US

V. Phone/Fax

Practice location:
  • Phone: 414-672-1353
  • Fax: 414-385-7551
Mailing address:
  • Phone: 414-672-1353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5426-226
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5426-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: