Provider Demographics
NPI:1255540027
Name:BECKETT, JESSICA LYNN (LPC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:BECKETT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:BAUER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:555 OAKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-1219
Mailing Address - Country:US
Mailing Address - Phone:608-617-5400
Mailing Address - Fax:
Practice Address - Street 1:317 DEWITT ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-2155
Practice Address - Country:US
Practice Address - Phone:608-617-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3590-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40997100Medicaid