Provider Demographics
NPI:1487675575
Name:BASCOM, JEANNE (MSW, LCSW, CADC)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:BASCOM
Suffix:
Gender:F
Credentials:MSW, LCSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W156N8327 PILGRIM RD
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-3776
Mailing Address - Country:US
Mailing Address - Phone:262-251-1112
Mailing Address - Fax:262-251-1113
Practice Address - Street 1:W156N8327 PILGRIM RD
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-3776
Practice Address - Country:US
Practice Address - Phone:262-251-1112
Practice Address - Fax:262-251-1113
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11174101YA0400X
WI3339-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40925700Medicaid
WI40925700Medicaid