MEDICARE: JEREMY J BURTCH LPC

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	101YM0800X	Mental Health Counselor	3249125	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3249125	OTHER	WI	LICENSED PROF COUNSELOR
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245319078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY J BURTCH LPC

Provider Business Mailing Address
First Line	:	602 PLEASANT OAK DR
Second Line	:
City	:	OREGON
State	:	WI
Zip	:	53575-3648
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	602 PLEASANT OAK DRIVE
Second Line	:
City	:	OREGON
State	:	WI
Zip	:	53575-3648
Country	:	US
Telephone Number	:	608-835-5050
Fax Number	:	608-835-5010

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

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	07/08/2007

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