Provider Demographics
NPI:1497229249
Name:JAMINSKI, KELLY MARIE
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:MARIE
Last Name:JAMINSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:COSTIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:324 S MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593
Mailing Address - Country:US
Mailing Address - Phone:608-244-4859
Mailing Address - Fax:608-244-6809
Practice Address - Street 1:324 S MAIN ST.
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593
Practice Address - Country:US
Practice Address - Phone:608-244-4859
Practice Address - Fax:608-244-6809
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1912499351Medicaid