Provider Demographics
NPI:1588228357
Name:GAINES, JASMINE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:GAINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 S 76TH ST APT 7
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53220-2344
Mailing Address - Country:US
Mailing Address - Phone:414-803-4317
Mailing Address - Fax:
Practice Address - Street 1:18740 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2936
Practice Address - Country:US
Practice Address - Phone:262-782-0230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-27
Last Update Date:2025-09-03
Deactivation Date:2020-08-17
Deactivation Code:
Reactivation Date:2020-09-01
Provider Licenses
StateLicense IDTaxonomies
WI11030-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI9010271841Medicaid