Basic Information
| Provider Information | |||||||||
| NPI: | 1386988293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | CSAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | W175N11120 STONEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530226511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623455560 | ||||||||
| FaxNumber: | 2623455531 | ||||||||
| Practice Location | |||||||||
| Address1: | 757 S MAIN ST | ||||||||
| Address2: | SUITE 8 | ||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549355739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207319798 | ||||||||
| FaxNumber: | 9207311097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2012 | ||||||||
| LastUpdateDate: | 11/16/2012 | ||||||||
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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 | 101YA0400X | 15702-132 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101Y00000X | 15702-132 | WI | N | Behavioral Health & Social Service Providers | Counselor |
No ID Information.