Healthcare Provider Details

I. General information

NPI: 1811815053
Provider Name (Legal Business Name): JENNIFER LYNN WILLACKER LPC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7280 S 13TH ST STE 202
OAK CREEK WI
53154-1831
US

IV. Provider business mailing address

2880 S LINEBARGER TER
MILWAUKEE WI
53207-2541
US

V. Phone/Fax

Practice location:
  • Phone: 262-251-1112
  • Fax:
Mailing address:
  • Phone: 414-704-6807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9164226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: