Healthcare Provider Details

I. General information

NPI: 1780867408
Provider Name (Legal Business Name): COUNTY OF GREEN LAKE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

571 COUNTY ROAD A
GREEN LAKE WI
54941
US

IV. Provider business mailing address

571 COUNTY ROAD A
GREEN LAKE WI
54941-8630
US

V. Phone/Fax

Practice location:
  • Phone: 920-294-4070
  • Fax: 920-294-4139
Mailing address:
  • Phone: 920-294-4070
  • Fax: 920-294-4139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. JASON N. JEROME
Title or Position: DIRECTOR
Credential:
Phone: 920-294-4070