Provider Demographics
NPI:1528274628
Name:GRACE, JP (MED, LPC)
Entity type:Individual
Prefix:
First Name:JP
Middle Name:
Last Name:GRACE
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 1:2095 WINNEBAGO ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-5316
Mailing Address - Country:US
Mailing Address - Phone:608-578-0005
Mailing Address - Fax:608-498-4588
Practice Address - Street 1:2095 WINNEBAGO ST
Practice Address - Street 2:SUITE A
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-5316
Practice Address - Country:US
Practice Address - Phone:608-578-0005
Practice Address - Fax:608-498-4588
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3258-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40947200Medicaid
WI3258-125OtherLICENSED PROF COUNSELOR