Provider Demographics
NPI:1881808533
Name:STRUHELKA, JACOB EDWARD (CLINICAL SUBSTANCE A)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:EDWARD
Last Name:STRUHELKA
Suffix:
Gender:M
Credentials:CLINICAL SUBSTANCE A
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3301 N BALLARD RD STE B
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-9002
Mailing Address - Country:US
Mailing Address - Phone:920-733-4443
Mailing Address - Fax:920-733-4796
Practice Address - Street 1:3301 N BALLARD RD STE B
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-9002
Practice Address - Country:US
Practice Address - Phone:920-733-4443
Practice Address - Fax:920-733-4796
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15257132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42018000Medicaid