Healthcare Provider Details

I. General information

NPI: 1194589986
Provider Name (Legal Business Name): JORDON M LIEBERT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JORDON M RETELLE

II. Dates (important events)

Enumeration Date: 02/12/2024
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 WASHINGTON AVE
OSHKOSH WI
54901-5030
US

IV. Provider business mailing address

220 WASHINGTON AVE
OSHKOSH WI
54901-5030
US

V. Phone/Fax

Practice location:
  • Phone: 920-236-4700
  • Fax:
Mailing address:
  • Phone: 920-236-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: