Provider Demographics
NPI:1780310748
Name:JACEK, CAITLIN ROSE (LCSW)
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:ROSE
Last Name:JACEK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CAITLIN
Other - Middle Name:ROSE
Other - Last Name:LEARNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:10806 W FREISTADT RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53097-2502
Mailing Address - Country:US
Mailing Address - Phone:847-757-5966
Mailing Address - Fax:
Practice Address - Street 1:10806 W FREISTADT RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-2502
Practice Address - Country:US
Practice Address - Phone:847-757-5966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490205991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical