Provider Demographics
NPI:1598880163
Name:GAINER, JAN
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:GAINER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JANICE
Other - Middle Name:
Other - Last Name:BADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9301 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-3752
Mailing Address - Country:US
Mailing Address - Phone:262-687-8611
Mailing Address - Fax:
Practice Address - Street 1:9301 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-3752
Practice Address - Country:US
Practice Address - Phone:262-687-8611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11265101YA0400X
WI546101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11013500Medicaid
WI520096Medicare ID - Type Unspecified