=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689838765
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELINE K BRENIZER SAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2008
-----------------------------------------------------
Last Update Date | 07/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24670 STATE ROAD 35 70 SUITE 1200
-----------------------------------------------------
City | SIREN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54872-4418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-349-7233
-----------------------------------------------------
Fax | 715-349-7205
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24670 STATE ROAD 35 70 SUITE 1200
-----------------------------------------------------
City | SIREN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54872-4418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-349-7233
-----------------------------------------------------
Fax | 715-349-7205
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 15434-131
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------