Provider Demographics
NPI:1295196202
Name:BOGDONOVICH, JEREMIAH JAMES
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:JAMES
Last Name:BOGDONOVICH
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 1:517 COURT ST
Mailing Address - Street 2:ROOM 503
Mailing Address - City:NEILLSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54456-1971
Mailing Address - Country:US
Mailing Address - Phone:715-743-5192
Mailing Address - Fax:715-743-5209
Practice Address - Street 1:517 COURT ST
Practice Address - Street 2:ROOM 503
Practice Address - City:NEILLSVILLE
Practice Address - State:WI
Practice Address - Zip Code:54456-1971
Practice Address - Country:US
Practice Address - Phone:715-743-5192
Practice Address - Fax:715-743-5209
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator