Provider Demographics
NPI:1033656079
Name:KUSSEROW, JESSE F (LPC)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:F
Last Name:KUSSEROW
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-1900
Mailing Address - Country:US
Mailing Address - Phone:920-541-6646
Mailing Address - Fax:
Practice Address - Street 1:2300 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-1900
Practice Address - Country:US
Practice Address - Phone:920-541-6646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-29
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7644125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional