Provider Demographics
NPI:1972714053
Name:KOEHL, JEREMY R (MSSW, LCSW,CADCIII)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:R
Last Name:KOEHL
Suffix:
Gender:M
Credentials:MSSW, LCSW,CADCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 WEST OMAHA STREET
Mailing Address - Street 2:
Mailing Address - City:WASHBURN
Mailing Address - State:WI
Mailing Address - Zip Code:54891-0036
Mailing Address - Country:US
Mailing Address - Phone:715-373-0160
Mailing Address - Fax:715-373-0162
Practice Address - Street 1:21 WEST OMAHA STREET
Practice Address - Street 2:
Practice Address - City:WASHBURN
Practice Address - State:WI
Practice Address - Zip Code:54891-0036
Practice Address - Country:US
Practice Address - Phone:715-373-0160
Practice Address - Fax:715-373-0162
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10748101YA0400X
WI2257-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39246100Medicaid