Healthcare Provider Details

I. General information

NPI: 1407764301
Provider Name (Legal Business Name): JAXON R. COLEMAN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ALONA LN
LANCASTER WI
53813-2202
US

IV. Provider business mailing address

200 W ALONA LN
LANCASTER WI
53813-2202
US

V. Phone/Fax

Practice location:
  • Phone: 608-723-6357
  • Fax: 608-723-4417
Mailing address:
  • Phone: 608-723-6357
  • Fax: 608-723-4417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9162-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: