Provider Demographics
NPI:1225168891
Name:PRUSCHA, JEAN MARIE (CSAC, ICS)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:MARIE
Last Name:PRUSCHA
Suffix:
Gender:F
Credentials:CSAC, ICS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N3157 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-3532
Mailing Address - Country:US
Mailing Address - Phone:262-249-0382
Mailing Address - Fax:
Practice Address - Street 1:840 LAKE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1566
Practice Address - Country:US
Practice Address - Phone:262-634-8688
Practice Address - Fax:262-634-7547
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11083-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39389200Medicaid