Healthcare Provider Details

I. General information

NPI: 1447476247
Provider Name (Legal Business Name): HIDDEN SPRINGS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 11/11/2008
Certification Date:
Deactivation Date: 08/07/2008
Reactivation Date: 11/11/2008

III. Provider practice location address

S1597 HANSON RD
WESTBY WI
54667-8396
US

IV. Provider business mailing address

S1597 HANSON RD
WESTBY WI
54667-8396
US

V. Phone/Fax

Practice location:
  • Phone: 608-634-2574
  • Fax: 608-634-6918
Mailing address:
  • Phone: 608-634-2574
  • Fax: 608-634-6918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2565
License Number StateWI

VIII. Authorized Official

Name: MR. DEAN ALAN JENSEN
Title or Position: OWNER DIRECTOR
Credential: MSE LPC
Phone: 608-634-2574