Provider Demographics
NPI:1265642318
Name:JACKIE NITSCHKE CENTER, INC.
Entity Type:Organization
Organization Name:JACKIE NITSCHKE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:LABINE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW ICS CSAC
Authorized Official - Phone:920-435-2093
Mailing Address - Street 1:630 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4931
Mailing Address - Country:US
Mailing Address - Phone:920-435-2093
Mailing Address - Fax:
Practice Address - Street 1:630 CHERRY ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4931
Practice Address - Country:US
Practice Address - Phone:920-435-2093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1446324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility