Provider Demographics
NPI:1265196679
Name:JASUTIS, REBECCA CHARLENE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:CHARLENE
Last Name:JASUTIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4918 SELL ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53027-9425
Mailing Address - Country:US
Mailing Address - Phone:872-236-3794
Mailing Address - Fax:
Practice Address - Street 1:10400 N BAEHR RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-4472
Practice Address - Country:US
Practice Address - Phone:833-646-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-22
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILJ232-7239-7958106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician