Basic Information
Provider Information | |||||||||
NPI: | 1922063965 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DARNELL | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | ROBERT | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 24691 EMBAY AVE | ||||||||
Address2: | APT B | ||||||||
City: | TOMAH | ||||||||
State: | WI | ||||||||
PostalCode: | 546604345 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8008728662 | ||||||||
FaxNumber: | 6083721779 | ||||||||
Practice Location | |||||||||
Address1: | 500 E VETERANS ST | ||||||||
Address2: | 425/7 | ||||||||
City: | TOMAH | ||||||||
State: | WI | ||||||||
PostalCode: | 546603105 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8008728662 | ||||||||
FaxNumber: | 6083721779 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/20/2006 | ||||||||
LastUpdateDate: | 04/28/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 989488 | CO | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | 989488 | CO | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.