Provider Demographics
NPI:1053453340
Name:PLATE, JACK A (LCSW,LMFT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:PLATE
Suffix:
Gender:M
Credentials:LCSW,LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4810 NORTHWESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-1504
Mailing Address - Country:US
Mailing Address - Phone:262-637-9984
Mailing Address - Fax:262-637-9995
Practice Address - Street 1:4810 NORTHWESTERN AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-1504
Practice Address - Country:US
Practice Address - Phone:262-637-9984
Practice Address - Fax:262-637-9995
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI698-1231041C0700X
WI209-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39534500Medicaid
WI0841480003Medicare ID - Type Unspecified