Healthcare Provider Details

I. General information

NPI: 1487843736
Provider Name (Legal Business Name): JACK WOOD MSSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 W BROWN DEER RD STE 200
BROWN DEER WI
53209-1220
US

IV. Provider business mailing address

1390 GREENWAY TER APT 2
BROOKFIELD WI
53005-6913
US

V. Phone/Fax

Practice location:
  • Phone: 414-540-2170
  • Fax:
Mailing address:
  • Phone: 262-957-4138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: