Provider Demographics
NPI:1891992749
Name:HALVERSON, JACQUELINE MAE (ATR-BC AND SADC)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:MAE
Last Name:HALVERSON
Suffix:
Gender:F
Credentials:ATR-BC AND SADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 S 55TH ST
Mailing Address - Street 2:
Mailing Address - City:W MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-5250
Mailing Address - Country:US
Mailing Address - Phone:414-546-1922
Mailing Address - Fax:
Practice Address - Street 1:1233 N. MAYFAIR RD
Practice Address - Street 2:206
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3255
Practice Address - Country:US
Practice Address - Phone:414-302-1233
Practice Address - Fax:414-302-1234
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI63-036101Y00000X
WI11505-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)