Healthcare Provider Details

I. General information

NPI: 1679497135
Provider Name (Legal Business Name): JAYLAH U BATEMON SAC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 MILLER PARK WAY
WEST MILWAUKEE WI
53214-3604
US

IV. Provider business mailing address

1610 MILLER PARK WAY STE 16001610
WEST MILWAUKEE WI
53214-3604
US

V. Phone/Fax

Practice location:
  • Phone: 414-672-3801
  • Fax: 414-672-6026
Mailing address:
  • Phone: 414-672-3801
  • Fax: 414-672-6026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number21045-130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: