Provider Demographics
NPI:1134787120
Name:ROSENBERG, JAYNE E
Entity type:Individual
Prefix:
First Name:JAYNE
Middle Name:E
Last Name:ROSENBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAYNE
Other - Middle Name:E
Other - Last Name:EMMRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-4799
Mailing Address - Country:US
Mailing Address - Phone:262-345-5533
Mailing Address - Fax:262-293-9737
Practice Address - Street 1:648 E DOVER ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-2108
Practice Address - Country:US
Practice Address - Phone:800-438-1772
Practice Address - Fax:262-345-5562
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4514-226101YP2500X
WI8193-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100095022Medicaid