Provider Demographics
NPI:1780867408
Name:COUNTY OF GREEN LAKE
Entity Type:Organization
Organization Name:COUNTY OF GREEN LAKE
Other - Org Name:GREEN LAKE COUNTY DHHS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:N
Authorized Official - Last Name:JEROME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-294-4070
Mailing Address - Street 1:571 COUNTY ROAD A
Mailing Address - Street 2:
Mailing Address - City:GREEN LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54941-8630
Mailing Address - Country:US
Mailing Address - Phone:920-294-4070
Mailing Address - Fax:920-294-4139
Practice Address - Street 1:571 COUNTY ROAD A
Practice Address - Street 2:
Practice Address - City:GREEN LAKE
Practice Address - State:WI
Practice Address - Zip Code:54941
Practice Address - Country:US
Practice Address - Phone:920-294-4070
Practice Address - Fax:920-294-4139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42139800Medicaid
WI42139800Medicaid
WIWI2364Medicare PIN