Healthcare Provider Details

I. General information

NPI: 1942695481
Provider Name (Legal Business Name): JEFFREY HERMAN MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 04/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 LAKELAND RD
SHAWANO WI
54166-3836
US

IV. Provider business mailing address

200 E PARK ST
BONDUEL WI
54107-8315
US

V. Phone/Fax

Practice location:
  • Phone: 715-526-5547
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: