Provider Demographics
NPI:1326489154
Name:PARADIGM ENRICHMENT SERVICES, INC
Entity Type:Organization
Organization Name:PARADIGM ENRICHMENT SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:414-393-0295
Mailing Address - Street 1:6110 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2120
Mailing Address - Country:US
Mailing Address - Phone:414-393-0295
Mailing Address - Fax:414-393-1155
Practice Address - Street 1:4222 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2500
Practice Address - Country:US
Practice Address - Phone:414-393-0295
Practice Address - Fax:414-393-1155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X, 103TA0400X, 103TA0400X
WI2990261QM0801X, 103TA0400X, 261Q00000X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK100130304Medicare PIN