Healthcare Provider Details

I. General information

NPI: 1518208206
Provider Name (Legal Business Name): JEREMY KEITH DAVIS LPCC, LPC, LADC, SAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2013
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 HUMBOLDT AVE S STE 100
BLOOMINGTON MN
55431-1433
US

IV. Provider business mailing address

405 STAGELINE RD
HUDSON WI
54016-1793
US

V. Phone/Fax

Practice location:
  • Phone: 952-454-0421
  • Fax:
Mailing address:
  • Phone: 715-531-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5690-125
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2076
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15822-131
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number305108
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: