Healthcare Provider Details

I. General information

NPI: 1114349636
Provider Name (Legal Business Name): JODY L DEBOER MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2014
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N8030 TOWNLINE RD
EAST TROY WI
53120-3500
US

IV. Provider business mailing address

N8030 TOWNLINE RD STE 501&502
EAST TROY WI
53120-3500
US

V. Phone/Fax

Practice location:
  • Phone: 262-441-6216
  • Fax:
Mailing address:
  • Phone: 262-441-6216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2019031458
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11474-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: