Healthcare Provider Details

I. General information

NPI: 1255126397
Provider Name (Legal Business Name): JEFFERY CONJURSKI SAC-IT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2025
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 VISTA RD
MANITOWOC WI
54220-9377
US

IV. Provider business mailing address

3 RIVERVIEW DR
MANITOWOC WI
54220-3767
US

V. Phone/Fax

Practice location:
  • Phone: 920-663-1035
  • Fax:
Mailing address:
  • Phone: 920-663-1035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20792130
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: