MEDICARE: MR. JEFFERSON DAVID FERGUSON LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	4885-125	WI

General Provider Information

NPI Number	:	1164533147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFERSON DAVID FERGUSON LPC

Provider Business Mailing Address
First Line	:	353 FOREST GROVE DR STE 100
Second Line	:
City	:	PEWAUKEE
State	:	WI
Zip	:	53072-3765
Country	:	US
Telephone Number	:	262-719-9470
Fax Number	:	262-691-2972

Provider Business Practice Location Address
First Line	:	353 FOREST GROVE DR STE 100
Second Line	:
City	:	PEWAUKEE
State	:	WI
Zip	:	53072-3765
Country	:	US
Telephone Number	:	262-719-9470
Fax Number	:	262-691-2972

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	09/10/2024

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