Basic Information
| Provider Information | |||||||||
| NPI: | 1518208206 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | KEITH | ||||||||
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| Credential: | LPCC, LPC, LADC, SAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 STAGELINE RD | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540161793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155316000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8200 HUMBOLDT AVE S STE 100 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554311433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524540421 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2013 | ||||||||
| LastUpdateDate: | 11/05/2019 | ||||||||
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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 | 101YM0800X | 5690-125 | WI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 2076 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | 15822-131 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 305108 | MN | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.