Provider Demographics
NPI:1669777611
Name:BURRIS, JENNIFER MARIE (LPC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:BURRIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:KOHLER
Mailing Address - State:WI
Mailing Address - Zip Code:53044-1430
Mailing Address - Country:US
Mailing Address - Phone:708-691-3663
Mailing Address - Fax:
Practice Address - Street 1:805 N 6TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4113
Practice Address - Country:US
Practice Address - Phone:708-691-3663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-24
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007572101YP2500X
WI5152-125101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional