Provider Demographics
NPI:1043510084
Name:SPANGENBERG, JACOB P (CSAC)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:P
Last Name:SPANGENBERG
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2979 ALLIED ST
Mailing Address - Street 2:UNIT C
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5567
Mailing Address - Country:US
Mailing Address - Phone:920-337-6740
Mailing Address - Fax:920-337-6741
Practice Address - Street 1:2979 ALLIED ST
Practice Address - Street 2:UNIT C
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5567
Practice Address - Country:US
Practice Address - Phone:920-337-6740
Practice Address - Fax:920-337-6741
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15832-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10063000Medicaid