Healthcare Provider Details

I. General information

NPI: 1700711553
Provider Name (Legal Business Name): JAKOB JERIMIAH REGAL PC-IT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N MAIN ST
POYNETTE WI
53955-9329
US

IV. Provider business mailing address

110 N MAIN ST
POYNETTE WI
53955-9329
US

V. Phone/Fax

Practice location:
  • Phone: 608-879-6135
  • Fax: 608-305-8896
Mailing address:
  • Phone: 608-879-6135
  • Fax: 608-305-8896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8508-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: