Provider Demographics
NPI:1033384797
Name:JEROME, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:JEROME
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53964-9068
Mailing Address - Country:US
Mailing Address - Phone:608-296-2139
Mailing Address - Fax:
Practice Address - Street 1:161 SPRING ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:WI
Practice Address - Zip Code:53964-9068
Practice Address - Country:US
Practice Address - Phone:608-296-2139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43701600Medicaid