Provider Demographics
NPI:1033656079
Name:KUSSEROW, JESSE (LPC-IT)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:KUSSEROW
Suffix:
Gender:M
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1822 S BOUTEN ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-1265
Mailing Address - Country:US
Mailing Address - Phone:920-427-0963
Mailing Address - Fax:
Practice Address - Street 1:1822 S BOUTEN ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1265
Practice Address - Country:US
Practice Address - Phone:920-427-0963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-29
Last Update Date:2017-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2103226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional