Provider Demographics
NPI:1932422953
Name:JACKETT, ANDREA K
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:K
Last Name:JACKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:KAY
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:2424 S 90TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2455
Practice Address - Country:US
Practice Address - Phone:414-328-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-04
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WI4796101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100186980Medicaid