Provider Demographics
NPI:1972939445
Name:WEISS, JACLYN A (LMFT)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:A
Last Name:WEISS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2475 UNIVERSITY AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-5099
Mailing Address - Country:US
Mailing Address - Phone:920-469-1201
Mailing Address - Fax:
Practice Address - Street 1:2475 UNIVERSITY AVE
Practice Address - Street 2:SUITE A
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-5099
Practice Address - Country:US
Practice Address - Phone:920-469-1201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI946-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist