Provider Demographics
NPI:1992915177
Name:ROUSSEAU, JERROLD BERNARD (MSSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:JERROLD
Middle Name:BERNARD
Last Name:ROUSSEAU
Suffix:
Gender:M
Credentials:MSSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5671 N MILWAUKEE RIVER PKWY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-4564
Mailing Address - Country:US
Mailing Address - Phone:414-228-9282
Mailing Address - Fax:
Practice Address - Street 1:6270 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4311
Practice Address - Country:US
Practice Address - Phone:414-962-2284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4219-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical