Provider Demographics
NPI:1275614919
Name:JEFFERSON COUNTY
Entity Type:Organization
Organization Name:JEFFERSON COUNTY
Other - Org Name:JEFFERSON COUNTY HUMAN SERVICE DEPT-MENTAL HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CAULEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-674-8111
Mailing Address - Street 1:1541 ANNEX RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:WI
Mailing Address - Zip Code:53549
Mailing Address - Country:US
Mailing Address - Phone:920-674-3105
Mailing Address - Fax:920-674-6113
Practice Address - Street 1:1541 ANNEX RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549
Practice Address - Country:US
Practice Address - Phone:920-674-3105
Practice Address - Fax:920-674-6113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1449261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42138100Medicaid
WI=========OtherUNITED HEALTHCARE
WI42138100Medicaid