Provider Demographics
NPI:1376509588
Name:JUERGENS, MARK W (LCSW LPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:JUERGENS
Suffix:
Gender:M
Credentials:LCSW LPC
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:W
Other - Last Name:JUERGENS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:4330 GOLF TER
Mailing Address - Street 2:SUITE 214
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4683
Mailing Address - Country:US
Mailing Address - Phone:715-833-2121
Mailing Address - Fax:715-833-2131
Practice Address - Street 1:4330 GOLF TER
Practice Address - Street 2:SUITE 214
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4683
Practice Address - Country:US
Practice Address - Phone:715-833-2121
Practice Address - Fax:715-833-2131
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1839125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40986200Medicaid
WI95846OtherSECURITY HEALTH PLAN
MN6250399OtherMEDICA UBH UHC
MNHP52029OtherHEALTH PARTNERS
MN574OtherBCBS MN