Provider Demographics
NPI:1821662867
Name:LINDSTRAND, JACOB ANTHONY THOMAS (MS, LPC-IT, SAC-IT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ANTHONY THOMAS
Last Name:LINDSTRAND
Suffix:
Gender:M
Credentials:MS, LPC-IT, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N3152 STATE ROAD 81
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-8821
Mailing Address - Country:US
Mailing Address - Phone:608-328-9352
Mailing Address - Fax:
Practice Address - Street 1:N3152 STATE ROAD 81
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-8821
Practice Address - Country:US
Practice Address - Phone:608-328-9352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-14
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19421101YA0400X
WI5338-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)