Healthcare Provider Details

I. General information

NPI: 1356197727
Provider Name (Legal Business Name): JENNIFER ANN SPORS SAC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2024
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 ELM ST
WEST BEND WI
53095-3205
US

IV. Provider business mailing address

6233 39TH AVE
KENOSHA WI
53142-7015
US

V. Phone/Fax

Practice location:
  • Phone: 262-353-9701
  • Fax:
Mailing address:
  • Phone: 262-654-1004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number7834-226
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20534-130
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12097-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: