Healthcare Provider Details

I. General information

NPI: 1306435508
Provider Name (Legal Business Name): JEREMY AVNER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 09/11/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16535 W BLUEMOUND RD
BROOKFIELD WI
53005-5936
US

IV. Provider business mailing address

16535 W BLUEMOUND RD STE 200
BROOKFIELD WI
53005-5906
US

V. Phone/Fax

Practice location:
  • Phone: 262-999-3495
  • Fax:
Mailing address:
  • Phone: 414-477-9517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number9119-123
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9119-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: