Provider Demographics
NPI:1699089490
Name:BRUMM-LARSON, JESSICA LYNN (PHD, LPC, NCSP)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LYNN
Last Name:BRUMM-LARSON
Suffix:
Gender:F
Credentials:PHD, LPC, NCSP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:BRUMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-2932
Mailing Address - Fax:414-266-3735
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-2932
Practice Address - Fax:414-266-3735
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3263-57103T00000X, 103T00000X
WI4723-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47037660631Medicaid
WI1699089490Medicaid