Provider Demographics
NPI:1851797070
Name:JAEGER, KIM MICHELE (LCSW SAC)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:MICHELE
Last Name:JAEGER
Suffix:
Gender:F
Credentials:LCSW SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N372 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:IXONIA
Mailing Address - State:WI
Mailing Address - Zip Code:53036-9508
Mailing Address - Country:US
Mailing Address - Phone:262-337-0641
Mailing Address - Fax:
Practice Address - Street 1:N372 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:IXONIA
Practice Address - State:WI
Practice Address - Zip Code:53036-9508
Practice Address - Country:US
Practice Address - Phone:262-337-0641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-16
Last Update Date:2014-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12723-131101YA0400X
WI1536-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)