Jaime Gunderson, LCSW, CSAC

Primary specialty

Social WorkerTaxonomy code 104100000X

License

131568-121 Issued in WI

Practice address

1446 Horicon St
Mayville, WI 53050-1467

Phone

(920) 539-0219

NPI assigned

Apr 10, 2017

Last updated

Oct 23, 2022By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in WI

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Clinical Social Worker

Education

Other, 2019

Medicare assignment

May accept Medicare assignment

Telehealth

Offers telehealth services

Group practices

Kettle Moraine Counseling LLCGroup PAC ID 8527353747, 20 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Kettle Moraine Counseling LLC

  dba Kettle Moraine Counseling

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • West Bend, WI
  • NPI 1568790954
  Medicare reassignment Care Compare group NPD
• Affiliated Clinical Services Inc

  • Multi-Specialty Clinic/Center
  • West Bend, WI
  • NPI 1851473698
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1491782400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1666483200000",
    "number": "1164955878",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "710 N MILWAUKEE ST",
            "city": "THERESA",
            "state": "WI",
            "postal_code": "530919716",
            "telephone_number": "920-539-0219"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1446 HORICON ST",
            "city": "MAYVILLE",
            "state": "WI",
            "postal_code": "530501467",
            "telephone_number": "920-539-0219"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GUNDERSON",
        "first_name": "JAIME",
        "credential": "LCSW, CSAC",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2017-04-10",
        "last_updated": "2022-10-23",
        "certification_date": "2022-10-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "WI",
            "license": "16566-132",
            "primary": false
        },
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "WI",
            "license": "131568-121",
            "primary": true
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "WI",
            "license": "9826-123",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1164955878",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kaitlyn Francour, OTR/L
• Daniel Frenette
• Sarah Mary Frings-Netys, DC
• Madeline Fritz, OTR/L
• Emily Michelle Gonzalez, LPC
• Fatmeh Hamdan
• James John Herget, DDS
• Herman School District 22
• Ashley Nicole Hettich, PT, DPT
• Cassandre Bezold Hetzer, O.D.

• Social Worker in Mayville, WI
• Providers in Mayville, WI by specialty
• Social Worker in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 23, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.