Provider Demographics
NPI:1376067942
Name:PUCKETT, JAMES EDWARD JR (MS)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:EDWARD
Last Name:PUCKETT
Suffix:JR
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 3RD ST N
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-6234
Mailing Address - Country:US
Mailing Address - Phone:608-519-5546
Mailing Address - Fax:
Practice Address - Street 1:600 3RD ST N
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-6234
Practice Address - Country:US
Practice Address - Phone:608-519-5547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-26
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6550-125101YP2500X
WI16168-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty