Provider Demographics
NPI:1588228357
Name:GAINES, JASMINE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:GAINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10125 W COLDSPRING RD APT 104
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53228-2628
Mailing Address - Country:US
Mailing Address - Phone:414-803-4317
Mailing Address - Fax:
Practice Address - Street 1:3505 N 124TH ST
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-2489
Practice Address - Country:US
Practice Address - Phone:414-431-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-27
Last Update Date:2020-09-01
Deactivation Date:2020-08-17
Deactivation Code:
Reactivation Date:2020-09-01
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI9010271841Medicaid