MEDICARE: JEFFREY L TAYLOR SR. CSAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	15483132	WI

General Provider Information

NPI Number	:	1083931927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY L TAYLOR SR. CSAC

Provider Business Mailing Address
First Line	:	2422 N GRANDVIEW BLVD
Second Line	:
City	:	WAUKESHA
State	:	WI
Zip	:	53188-6105
Country	:	US
Telephone Number	:	262-549-6600
Fax Number	:	262-549-6698

Provider Business Practice Location Address
First Line	:	1610 MILLER PARK WAY
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53214-3604
Country	:	US
Telephone Number	:	262-549-6600
Fax Number	:	262-549-6698

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2010
Last Update Date	:	08/16/2010

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