1376509588 NPI number — MARK W JUERGENS LCSW LPC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376509588 NPI number — MARK W JUERGENS LCSW LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JUERGENS
Provider First Name:
MARK
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW LPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JUERGENS
Provider Other First Name:
MARK
Provider Other Middle Name:
W
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1376509588
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4330 GOLF TER
Provider Second Line Business Mailing Address:
SUITE 214
Provider Business Mailing Address City Name:
EAU CLAIRE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54701-4683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-833-2121
Provider Business Mailing Address Fax Number:
715-833-2131

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4330 GOLF TER
Provider Second Line Business Practice Location Address:
SUITE 214
Provider Business Practice Location Address City Name:
EAU CLAIRE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54701-4683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-833-2121
Provider Business Practice Location Address Fax Number:
715-833-2131
Provider Enumeration Date:
04/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  1839125 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 40986200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 95846 . This is a "SECURITY HEALTH PLAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 6250399 . This is a "MEDICA UBH UHC" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP52029 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 574 . This is a "BCBS MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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