Provider Demographics
NPI:1669872818
Name:DIAZ, JESSICA (LPC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:SCHEUNEMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:9000 W WISCONSIN AVE # MS 958
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-7615
Mailing Address - Fax:414-266-6238
Practice Address - Street 1:619 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3839
Practice Address - Country:US
Practice Address - Phone:414-810-3548
Practice Address - Fax:414-810-3590
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5415-125101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1669872818Medicaid