Provider Demographics
NPI:1487676508
Name:STUMBRAS, JEFFERY JON (MSW)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:JON
Last Name:STUMBRAS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2680 VERNON DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5374
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:920-496-4705
Practice Address - Street 1:2680 VERNON DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5374
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:920-496-4705
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22961041C0700X
WI248106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39578400Medicaid
WI39578400Medicaid
07125-0121Medicare ID - Type Unspecified
WI07028Medicare PIN