MEDICARE: MARK W JUERGENS LCSW 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	1839125	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	95846	OTHER	WI	SECURITY HEALTH PLAN
3	6250399	OTHER	MN	MEDICA UBH UHC
4	HP52029	OTHER	MN	HEALTH PARTNERS
5	574	OTHER	MN	BCBS MN

General Provider Information

NPI Number	:	1376509588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK W JUERGENS LCSW LPC

Provider Business Mailing Address
First Line	:	4330 GOLF TER
Second Line	:	SUITE 214
City	:	EAU CLAIRE
State	:	WI
Zip	:	54701-4683
Country	:	US
Telephone Number	:	715-833-2121
Fax Number	:	715-833-2131

Provider Business Practice Location Address
First Line	:	4330 GOLF TER
Second Line	:	SUITE 214
City	:	EAU CLAIRE
State	:	WI
Zip	:	54701-4683
Country	:	US
Telephone Number	:	715-833-2121
Fax Number	:	715-833-2131

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

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	05/08/2013

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