Provider Demographics
NPI:1306954920
Name:JESSEN, GRACE LOUISE (LCSW)
Entity type:Individual
Prefix:MS
First Name:GRACE
Middle Name:LOUISE
Last Name:JESSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:GRACE
Other - Middle Name:L
Other - Last Name:MCCUTCHEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:W62N248 WASHINGTON AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-2768
Mailing Address - Country:US
Mailing Address - Phone:262-375-1116
Mailing Address - Fax:
Practice Address - Street 1:207 E BUFFALO ST
Practice Address - Street 2:SUITE 510
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-5739
Practice Address - Country:US
Practice Address - Phone:262-375-7022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3469-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40917300Medicaid