Provider Demographics
NPI:1659711687
Name:GJB HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:GJB HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ACCESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BANNASCH
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:920-217-7861
Mailing Address - Street 1:711 N LYNNDALE DR STE 1A
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-3078
Mailing Address - Country:US
Mailing Address - Phone:920-560-4525
Mailing Address - Fax:920-560-6618
Practice Address - Street 1:711 N LYNNDALE DR STE 1A
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-3078
Practice Address - Country:US
Practice Address - Phone:920-560-4585
Practice Address - Fax:920-560-6618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-05
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100077381Medicaid