Provider Demographics
NPI:1437394285
Name:KERCKHOVE, JESSICA G (BA, SAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:G
Last Name:KERCKHOVE
Suffix:
Gender:F
Credentials:BA, SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5533 166TH ST
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-6916
Mailing Address - Country:US
Mailing Address - Phone:715-559-4563
Mailing Address - Fax:
Practice Address - Street 1:320 21ST ST N
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-2228
Practice Address - Country:US
Practice Address - Phone:715-235-4537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15453-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)