Healthcare Provider Details

I. General information

NPI: 1548498298
Provider Name (Legal Business Name): JARED M. KOHLENBERG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 05/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 COUNTY ROAD A
GREEN LAKE WI
54941-8608
US

IV. Provider business mailing address

670 COUNTY ROAD A
GREEN LAKE WI
54941-8608
US

V. Phone/Fax

Practice location:
  • Phone: 920-294-0100
  • Fax: 920-294-0123
Mailing address:
  • Phone: 920-294-0100
  • Fax: 920-294-0123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number57315-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: