Provider Demographics
NPI:1265721161
Name:SIMON, JAIMIE (SAC, LPC)
Entity type:Individual
Prefix:
First Name:JAIMIE
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:SAC, LPC
Other - Prefix:
Other - First Name:JAIMIE
Other - Middle Name:
Other - Last Name:HENSCHEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 CROOKS ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4527
Mailing Address - Country:US
Mailing Address - Phone:920-436-6800
Mailing Address - Fax:920-432-5966
Practice Address - Street 1:300 CROOKS ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4527
Practice Address - Country:US
Practice Address - Phone:920-436-6800
Practice Address - Fax:920-432-5966
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15801-131101YA0400X
WI5130-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1265721161Medicaid