Provider Demographics
NPI:1144454927
Name:BEHRENS, JACOB M (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:M
Last Name:BEHRENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4221 W LE GRANDE BLVD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5220
Mailing Address - Country:US
Mailing Address - Phone:920-450-4947
Mailing Address - Fax:888-866-4665
Practice Address - Street 1:1045 W GLEN OAKS LN
Practice Address - Street 2:STE 205
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-5320
Practice Address - Country:US
Practice Address - Phone:414-909-2343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-08
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN623012084P0800X
IDMC-00012084P0800X
WI55027-202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry