MEDICARE: JACLYN A WEISS LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	946-124	WI

General Provider Information

NPI Number	:	1972939445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN A WEISS LMFT

Provider Business Mailing Address
First Line	:	2475 UNIVERSITY AVE
Second Line	:	SUITE A
City	:	GREEN BAY
State	:	WI
Zip	:	54302-5099
Country	:	US
Telephone Number	:	920-469-1201
Fax Number	:

Provider Business Practice Location Address
First Line	:	2475 UNIVERSITY AVE
Second Line	:	SUITE A
City	:	GREEN BAY
State	:	WI
Zip	:	54302-5099
Country	:	US
Telephone Number	:	920-469-1201
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2013
Last Update Date	:	09/17/2013

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