Provider Demographics
NPI:1376941963
Name:PSYCH MED MANAGEMENT LLC
Entity Type:Organization
Organization Name:PSYCH MED MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESE
Authorized Official - Middle Name:
Authorized Official - Last Name:JAECKLE
Authorized Official - Suffix:
Authorized Official - Credentials:APNP
Authorized Official - Phone:414-530-1878
Mailing Address - Street 1:140 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:THIENSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53092-1956
Mailing Address - Country:US
Mailing Address - Phone:262-402-7964
Mailing Address - Fax:262-261-5062
Practice Address - Street 1:140 S MAIN ST
Practice Address - Street 2:
Practice Address - City:THIENSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53092-1956
Practice Address - Country:US
Practice Address - Phone:262-402-7964
Practice Address - Fax:262-261-5062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-12
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3319-33251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1063696516Medicaid