Provider Demographics
NPI:1063819803
Name:KAHN, JERRY (LCSW)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:KAHN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10150 W NATIONAL AVE STE 370
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2152
Mailing Address - Country:US
Mailing Address - Phone:262-782-2090
Mailing Address - Fax:262-782-2092
Practice Address - Street 1:10150 W NATIONAL AVE STE 370
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2152
Practice Address - Country:US
Practice Address - Phone:262-782-2090
Practice Address - Fax:262-782-2092
Is Sole Proprietor?:No
Enumeration Date:2014-11-21
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9247-1231041C0700X
WI10063-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No183500000XPharmacy Service ProvidersPharmacist