Provider Demographics
NPI:1528467495
Name:MATER, JESSICA (SAC-IT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MATER
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9910 W LAYTON AVE
Mailing Address - Street 2:SUITE #2
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53228-3363
Mailing Address - Country:US
Mailing Address - Phone:414-427-4884
Mailing Address - Fax:
Practice Address - Street 1:9910 W LAYTON AVE
Practice Address - Street 2:SUITE #2
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-3363
Practice Address - Country:US
Practice Address - Phone:414-427-4884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-17
Last Update Date:2014-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17136-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)