Provider Demographics
NPI:1669004198
Name:JACOBY MCCRACKEN, KATIE (CAPSW, SAC-IT)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:JACOBY MCCRACKEN
Suffix:
Gender:F
Credentials:CAPSW, SAC-IT
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:JACOBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAPSW, SAC-IT
Mailing Address - Street 1:PO BOX 22308
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2308
Mailing Address - Country:US
Mailing Address - Phone:920-436-6800
Mailing Address - Fax:920-432-5966
Practice Address - Street 1:300 CROOKS ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4527
Practice Address - Country:US
Practice Address - Phone:920-436-6800
Practice Address - Fax:920-432-5966
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17661101YA0400X
WI16558101YA0400X
WI130643104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1669004198Medicaid