=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205644747
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JADE ALEXIS LISOWICZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2024
-----------------------------------------------------
Last Update Date | 12/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6140 W EXECUTIVE DR
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53092-4499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-754-0398
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1205 ALDER ST
-----------------------------------------------------
City | WEST BEND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53090-1707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-336-7086
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------