MEDICARE: A KEY TO THE STREETS FOUNDATION INC.

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1992410500
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A KEY TO THE STREETS FOUNDATION INC.

Provider Business Mailing Address
First Line	:	PO BOX 5483
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53205-0483
Country	:	US
Telephone Number	:	414-759-4730
Fax Number	:

Provider Business Practice Location Address
First Line	:	7010 N 60TH ST APT 101
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53223-5112
Country	:	US
Telephone Number	:	414-759-4730
Fax Number	:

Authorized Official
Title or Position	:	MENTAL HEALTH THERAPIST
Name	:	SHAQUAN L JEFFERSON
Credential	:	MA-LPC-IT
Telephone Number	:	414-759-4730

Provider Enumeration Date	:	01/18/2023
Last Update Date	:	01/18/2023

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