Provider Demographics
NPI:1912209925
Name:STACHE, JEFFREY W
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:W
Last Name:STACHE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CHRISTOPHER CT
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-2321
Mailing Address - Country:US
Mailing Address - Phone:262-567-1302
Mailing Address - Fax:
Practice Address - Street 1:1200 CHRISTOPHER CT
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-2321
Practice Address - Country:US
Practice Address - Phone:262-567-1302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional