Healthcare Provider Details

I. General information

NPI: 1932720430
Provider Name (Legal Business Name): JORDAN BREE BRUNNER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JORDAN B LESUER-MANDERNACK

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 W WASHINGTON ST
WEST BEND WI
53095-2430
US

IV. Provider business mailing address

PO BOX 959
SHEBOYGAN WI
53082-0959
US

V. Phone/Fax

Practice location:
  • Phone: 920-783-6633
  • Fax: 920-783-6392
Mailing address:
  • Phone: 920-783-6633
  • Fax: 920-783-6392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4501-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: