MEDICARE: JEFF MICHAEL HALL SOCIAL WORKER

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	1041C0700X	Clinical Social Worker	7153123	WI

General Provider Information

NPI Number	:	1356396063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFF MICHAEL HALL SOCIAL WORKER

Provider Business Mailing Address
First Line	:	112 PARKWOOD DR
Second Line	:
City	:	WRENSHALL
State	:	MN
Zip	:	55797-9055
Country	:	US
Telephone Number	:	218-384-3518
Fax Number	:

Provider Business Practice Location Address
First Line	:	3520 TOWER AVE
Second Line	:
City	:	SUPERIOR
State	:	WI
Zip	:	54880-5335
Country	:	US
Telephone Number	:	715-398-2914
Fax Number	:

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

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	07/08/2007

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