Provider Demographics
NPI:1164955878
Name:GUNDERSON, JAIME (LCSW, CSAC)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:LCSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:THERESA
Mailing Address - State:WI
Mailing Address - Zip Code:53091-9716
Mailing Address - Country:US
Mailing Address - Phone:920-539-0219
Mailing Address - Fax:
Practice Address - Street 1:1446 HORICON ST
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:WI
Practice Address - Zip Code:53050-1467
Practice Address - Country:US
Practice Address - Phone:920-539-0219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2022-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9826-1231041C0700X
WI16566-132101YA0400X
WI131568-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1164955878Medicaid