Provider Demographics
NPI:1689838765
Name:BRENIZER, JACQUELINE K (SAC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:K
Last Name:BRENIZER
Suffix:
Gender:F
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24670 STATE ROAD 35 70
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:SIREN
Mailing Address - State:WI
Mailing Address - Zip Code:54872-4418
Mailing Address - Country:US
Mailing Address - Phone:715-349-7233
Mailing Address - Fax:715-349-7205
Practice Address - Street 1:24670 STATE ROAD 35 70
Practice Address - Street 2:SUITE 1200
Practice Address - City:SIREN
Practice Address - State:WI
Practice Address - Zip Code:54872-4418
Practice Address - Country:US
Practice Address - Phone:715-349-7233
Practice Address - Fax:715-349-7205
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15434-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)