Provider Demographics
NPI:1689843831
Name:JEFFERSON COUNTY
Entity Type:Organization
Organization Name:JEFFERSON COUNTY
Other - Org Name:JEFFERSON COUNTY HUMAN SERVICES-CRISIS INTERVENTION RENDERING PROVIDER
Other - Org Type:Other Name
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GEBAUER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:920-674-3105
Mailing Address - Street 1:1541 ANNEX RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:WI
Mailing Address - Zip Code:53549-9803
Mailing Address - Country:US
Mailing Address - Phone:920-674-3105
Mailing Address - Fax:920-674-6113
Practice Address - Street 1:1541 ANNEX RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-9803
Practice Address - Country:US
Practice Address - Phone:920-674-3105
Practice Address - Fax:920-674-6113
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFERSON COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-21
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1449251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32980900Medicaid