Basic Information
| Provider Information | |||||||||
| NPI: | 1073234191 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZAVALA | ||||||||
| FirstName: | JEESENIA | ||||||||
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| Credential: | QTT-LPC-IT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1337 S CESAR E CHAVEZ DR | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532042712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148975511 | ||||||||
| FaxNumber: | 4143857552 | ||||||||
| Practice Location | |||||||||
| Address1: | 2906 S 20TH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532153732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146721353 | ||||||||
| FaxNumber: | 4143857551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2022 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 5426-226 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 101YP2500X | 5426-226 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.