Provider Demographics
NPI:1043303787
Name:LANDERS, JACQUELINE LEE (MSW LCSW CSAC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LEE
Last Name:LANDERS
Suffix:
Gender:F
Credentials:MSW LCSW CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15460 W CAPITOL DR STE 222
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-2632
Mailing Address - Country:US
Mailing Address - Phone:262-408-0588
Mailing Address - Fax:262-373-0362
Practice Address - Street 1:15460 W CAPITOL DR STE 222
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-2632
Practice Address - Country:US
Practice Address - Phone:262-408-0588
Practice Address - Fax:262-373-0362
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2020-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11947101YA0400X
WI6864-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40922200Medicaid