Healthcare Provider Details

I. General information

NPI: 1184690679
Provider Name (Legal Business Name): JEAN A DAUTE MS LPC CSAC ICS MAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 07/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 W MAIN ST SUITE 207
STOUGHTON WI
53589-2100
US

IV. Provider business mailing address

135 W MAIN ST SUITE 207
STOUGHTON WI
53589-2100
US

V. Phone/Fax

Practice location:
  • Phone: 608-873-7838
  • Fax: 877-674-2177
Mailing address:
  • Phone: 608-873-7838
  • Fax: 877-674-2177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1453
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3118-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: