Provider Demographics
NPI:1487843736
Name:WOOD, JACK (MSSW)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:WOOD
Suffix:
Gender:M
Credentials:MSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1390 GREENWAY TER APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-6913
Mailing Address - Country:US
Mailing Address - Phone:262-957-4138
Mailing Address - Fax:
Practice Address - Street 1:3900 W BROWN DEER RD STE 200
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53209-1220
Practice Address - Country:US
Practice Address - Phone:414-540-2170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42244700Medicaid