Provider Demographics
NPI:1518208206
Name:DAVIS, JEREMY KEITH (LPCC, LPC, LADC, SAC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:KEITH
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LPCC, LPC, LADC, SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 STAGELINE RD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-1793
Mailing Address - Country:US
Mailing Address - Phone:715-531-6000
Mailing Address - Fax:
Practice Address - Street 1:8200 HUMBOLDT AVE S STE 100
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-1433
Practice Address - Country:US
Practice Address - Phone:952-454-0421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5690-125101YM0800X
MN2076101YM0800X
WI15822-131101YA0400X
MN305108101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)