Provider Demographics
NPI:1417688771
Name:EIDEN, JESSIKA ELLEN
Entity Type:Individual
Prefix:
First Name:JESSIKA
Middle Name:ELLEN
Last Name:EIDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSIKA
Other - Middle Name:ELLEN
Other - Last Name:GERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:N91W16170 JUNCTION WAY APT 201
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-3242
Mailing Address - Country:US
Mailing Address - Phone:608-469-2766
Mailing Address - Fax:
Practice Address - Street 1:2607 N GRANDVIEW BLVD STE 110
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1690
Practice Address - Country:US
Practice Address - Phone:262-313-8339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7284-226101Y00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor