Provider Demographics
NPI:1710223177
Name:OSMUNSON, JESSICA M (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:OSMUNSON
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MISHICOT
Mailing Address - State:WI
Mailing Address - Zip Code:54228-9528
Mailing Address - Country:US
Mailing Address - Phone:920-973-1008
Mailing Address - Fax:
Practice Address - Street 1:123 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2831
Practice Address - Country:US
Practice Address - Phone:920-973-1008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-12
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI983-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100027626Medicaid