Provider Demographics
NPI:1013087675
Name:BALLOU, JEFFREY BLAKE (LCP, LP)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:BLAKE
Last Name:BALLOU
Suffix:
Gender:M
Credentials:LCP, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 W CLAIREMONT AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4566
Mailing Address - Country:US
Mailing Address - Phone:715-834-2046
Mailing Address - Fax:715-834-7563
Practice Address - Street 1:2231 CATLIN AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5137
Practice Address - Country:US
Practice Address - Phone:715-394-4173
Practice Address - Fax:715-394-9182
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2024-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI591-125101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39259800Medicaid