MEDICARE: MR. JERROLD BERNARD ROUSSEAU MSSW, LCSW

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	1041C0700X	Clinical Social Worker	4219-123	WI

General Provider Information

NPI Number	:	1992915177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JERROLD BERNARD ROUSSEAU MSSW, LCSW

Provider Business Mailing Address
First Line	:	5671 N MILWAUKEE RIVER PKWY
Second Line	:
City	:	GLENDALE
State	:	WI
Zip	:	53209-4564
Country	:	US
Telephone Number	:	414-228-9282
Fax Number	:

Provider Business Practice Location Address
First Line	:	6270 N PORT WASHINGTON RD
Second Line	:	SUITE 201
City	:	GLENDALE
State	:	WI
Zip	:	53217-4311
Country	:	US
Telephone Number	:	414-962-2284
Fax Number	:

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	07/08/2007

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