Provider Demographics
NPI:1720201163
Name:NORTHSHORE CLINIC & CONSULTANTS, INC.
Entity Type:Organization
Organization Name:NORTHSHORE CLINIC & CONSULTANTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THERESE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JAECKLE
Authorized Official - Suffix:
Authorized Official - Credentials:APNP
Authorized Official - Phone:262-375-1116
Mailing Address - Street 1:W62N248 WASHINGTON AVE
Mailing Address - Street 2:SUITE #207
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-2768
Mailing Address - Country:US
Mailing Address - Phone:262-375-1116
Mailing Address - Fax:262-375-1071
Practice Address - Street 1:W62N248 WASHINGTON AVE
Practice Address - Street 2:SUITE #207
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-2768
Practice Address - Country:US
Practice Address - Phone:262-375-1116
Practice Address - Fax:262-375-1071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1695251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI084862Medicare PIN
WI44295Medicare PIN