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General NPI Number Information
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NPI Number | 1124798970
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Entity Type | Organization
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Legal Business Name | JACOB'S WELL PRESBYTERIAN CHURCH
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Dates
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Enumeration Date | 09/14/2021
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Last Update Date | 09/14/2021
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Provider Practice Location Address
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Address Line | 3340 LINEVILLE RD
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City | GREEN BAY
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State | WI
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Zip | 54313-7237
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Country | US
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Telephone | 920-264-9564
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Fax |
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Provider Business Mailing Address
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Address Line | 3340 LINEVILLE RD
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City | GREEN BAY
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State | WI
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Zip | 54313-7237
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Country | US
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Telephone | 920-264-9564
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | SPENCER REA HANSEN THOMAS
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Credential | LPC, NCC
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Telephone | 309-532-2364
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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