Provider Demographics
NPI:1053059592
Name:JEFFERSON, HOLLISTER L (MA, SAC-IT)
Entity Type:Individual
Prefix:
First Name:HOLLISTER
Middle Name:L
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:MA, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6223 W STEVENSON ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53213-4163
Mailing Address - Country:US
Mailing Address - Phone:414-587-2212
Mailing Address - Fax:
Practice Address - Street 1:400 W RIVER DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53090-1518
Practice Address - Country:US
Practice Address - Phone:262-334-4340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19467101YA0400X
WI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)