Provider Demographics
NPI:1457710204
Name:PALMBACH, JILLIAN LEE (17632-130)
Entity type:Individual
Prefix:MS
First Name:JILLIAN
Middle Name:LEE
Last Name:PALMBACH
Suffix:
Gender:F
Credentials:17632-130
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 W GLENPARK DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-1571
Mailing Address - Country:US
Mailing Address - Phone:920-538-6261
Mailing Address - Fax:
Practice Address - Street 1:3301 N BALLARD RD
Practice Address - Street 2:STE B
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8928
Practice Address - Country:US
Practice Address - Phone:920-733-4443
Practice Address - Fax:920-733-4796
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17632-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)