Healthcare Provider Details

I. General information

NPI: 1841825601
Provider Name (Legal Business Name): ANNA JACQUES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNA KREMER

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 N MAYFAIR RD STE 650
WAUWATOSA WI
53226-1322
US

IV. Provider business mailing address

3155 N 87TH ST
MILWAUKEE WI
53222-3730
US

V. Phone/Fax

Practice location:
  • Phone: 414-771-9304
  • Fax: 414-771-9543
Mailing address:
  • Phone: 920-810-4281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: