Basic Information
| Provider Information | |||||||||
| NPI: | 1699796797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIVINGSTON | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | STEWART | ||||||||
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| Credential: | MS, LPC, SAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 NEBRASKA ST | ||||||||
| Address2: | DOOR COUNTY DEPARTMENT OF COMMUNITY PROGRAMS | ||||||||
| City: | STURGEON BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542352225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207462345 | ||||||||
| FaxNumber: | 9207462439 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 NEBRASKA ST | ||||||||
| Address2: | DOOR COUNTY DEPARTMENT OF COMMUNITY PROGRAMS | ||||||||
| City: | STURGEON BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542352225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207462345 | ||||||||
| FaxNumber: | 9207462439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 05/10/2011 | ||||||||
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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 | 101YP2500X | 2583 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 39731200 | 05 | WI | MEDICAID |