Healthcare Provider Details

I. General information

NPI: 1861052078
Provider Name (Legal Business Name): BETHANY N JARK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETHANY N KROMBHOLZ

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 REID ST STE N
DE PERE WI
54115-2164
US

IV. Provider business mailing address

400 REID ST STE N
DE PERE WI
54115-2164
US

V. Phone/Fax

Practice location:
  • Phone: 715-842-9500
  • Fax: 715-848-0425
Mailing address:
  • Phone: 715-842-9500
  • Fax: 715-848-0425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8642-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: