Provider Demographics
NPI:1316130404
Name:SCHROEDER, JESSICA R (PSYD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:SCHROEDER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W WISCONSIN AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-3551
Mailing Address - Country:US
Mailing Address - Phone:920-257-4601
Mailing Address - Fax:
Practice Address - Street 1:1000 W WISCONSIN AVE STE 1
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-3551
Practice Address - Country:US
Practice Address - Phone:920-257-4601
Practice Address - Fax:920-257-4603
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
WI2881-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1316130404Medicaid