Basic Information
| Provider Information | |||||||||
| NPI: | 1255646337 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KERRIGAN | ||||||||
| FirstName: | JOE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 4TH ST N | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546013228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087856101 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 4TH ST N | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546013228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087856101 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2010 | ||||||||
| LastUpdateDate: | 08/12/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 0000084273 | 05 | WI | MEDICAID |