NPIMap

Organization Active NPI

Psych Med Management LLC

  • Community/Behavioral Health Agency
  • Thiensville, WI
National Provider Identifier
1376941963
Registry record updated Dec 12, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Behavioral Health AgencyTaxonomy code 251S00000X
License
3319-33 Issued in WI
Legal business name
PSYCH MED MANAGEMENT LLC
Practice address
140 S Main St
Thiensville, WI 53092-1956
Phone
(262) 402-7964
Fax
(262) 261-5062
NPI assigned
Dec 12, 2014
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 12, 2014

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

Authorized official

Name
Ms. Therese Jaeckle, APNPNPI 1063696516
Title
Owner
Phone
(414) 530-1878

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Behavioral Health Agency 251S00000X 3319-33 WI Primary

Addresses

Primary practice location

140 S Main St
Thiensville, WI 53092-1956

Mailing address

140 S Main St
Thiensville, WI 53092-1956
Phone (262) 402-7964

Other identifiers 1

IdentifierTypeStateIssuer
1063696516MedicaidWI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150420000124 WI Part B Supplier - Clinic/Group Practice 5294053443 Receives reassigned benefits from 3 practitioners
Practice locations: Brookfield, WI; Mequon, WI

National Provider Directory

National Provider Directory

Locations

13965 W Burleigh Rd
#103
Brookfield, WI 53005
Phone (262) 402-7964

11431 N Port Washington Rd
Ste 115
Mequon, WI 53092
Phone (262) 402-7964

136 N Main St
#304
Thiensville, WI 53092
Phone (262) 402-7964

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1418342400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1418342400000",
    "number": "1376941963",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "140 S MAIN ST",
            "city": "THIENSVILLE",
            "state": "WI",
            "postal_code": "530921956",
            "telephone_number": "262-402-7964",
            "fax_number": "262-261-5062"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "140 S MAIN ST",
            "city": "THIENSVILLE",
            "state": "WI",
            "postal_code": "530921956",
            "telephone_number": "262-402-7964",
            "fax_number": "262-261-5062"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PSYCH MED MANAGEMENT LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-12-12",
        "last_updated": "2014-12-12",
        "status": "A",
        "authorized_official_last_name": "JAECKLE",
        "authorized_official_first_name": "THERESE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "414-530-1878",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "APNP"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "WI",
            "license": "3319-33",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1063696516",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Thiensville, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 12, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.