Provider Demographics
NPI:1164006573
Name:JACOBS WELL PRESBYTERIAN CHURCHA
Entity Type:Organization
Organization Name:JACOBS WELL PRESBYTERIAN CHURCHA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PASTOR OF CARE AND COUNSELING
Authorized Official - Prefix:
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:REA HANSEN
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:309-532-2364
Mailing Address - Street 1:3340 LINEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-7237
Mailing Address - Country:US
Mailing Address - Phone:920-264-9564
Mailing Address - Fax:
Practice Address - Street 1:3340 LINEVILLE RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-7237
Practice Address - Country:US
Practice Address - Phone:920-264-9564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)