Provider Demographics
NPI:1194774893
Name:O'BRIEN, JENNIFER GRIMES (MED, LPC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GRIMES
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 W MARKET ST # 1J
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5098
Mailing Address - Country:US
Mailing Address - Phone:414-239-0363
Mailing Address - Fax:
Practice Address - Street 1:1500 W MARKET ST
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5098
Practice Address - Country:US
Practice Address - Phone:414-239-0363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4704125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health