Provider Demographics
NPI:1619558509
Name:MCKAY SILLMAN, JENNIFER ROSE (LPC-IT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:MCKAY SILLMAN
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N7706 NEWVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:WI
Mailing Address - Zip Code:53594-9441
Mailing Address - Country:US
Mailing Address - Phone:920-210-7608
Mailing Address - Fax:
Practice Address - Street 1:119 N MCCARTHY RD STE P
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-9112
Practice Address - Country:US
Practice Address - Phone:920-903-1060
Practice Address - Fax:920-903-1164
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4942226101YP2500X
WI4942-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100187166Medicaid