MEDICARE: JEREMY KOERSELMAN LISW

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1578711594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY KOERSELMAN LISW

Provider Business Mailing Address
First Line	:	111 ARIZONA AVE NW
Second Line	:
City	:	ORANGE CITY
State	:	IA
Zip	:	51041-1425
Country	:	US
Telephone Number	:	712-737-9444
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 ARIZONA AVE NW
Second Line	:
City	:	ORANGE CITY
State	:	IA
Zip	:	51041-1425
Country	:	US
Telephone Number	:	712-737-9444
Fax Number	:

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

Provider Enumeration Date	:	09/03/2008
Last Update Date	:	04/29/2016

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