Provider Demographics
NPI:1346325446
Name:GAETHKE, JAY WILLIAM (LPC, SAC, CSW)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:WILLIAM
Last Name:GAETHKE
Suffix:
Gender:M
Credentials:LPC, SAC, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 ELM GROVE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2546
Mailing Address - Country:US
Mailing Address - Phone:262-782-2090
Mailing Address - Fax:262-782-2092
Practice Address - Street 1:500 ELM GROVE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2546
Practice Address - Country:US
Practice Address - Phone:262-782-2090
Practice Address - Fax:262-782-2092
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YA0400X
WI3912101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)