Provider Demographics
NPI:1477877793
Name:COMSTOCK, JANE
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:COMSTOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W20298 STATE ROAD 121
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:WI
Mailing Address - Zip Code:54773-9685
Mailing Address - Country:US
Mailing Address - Phone:715-538-4312
Mailing Address - Fax:
Practice Address - Street 1:W20298 STATE ROAD 121
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:WI
Practice Address - Zip Code:54773-9685
Practice Address - Country:US
Practice Address - Phone:715-538-4312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1635-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1635-132Medicare PIN