Provider Demographics
NPI:1538373022
Name:TAYLOR COUNTY
Entity type:Organization
Organization Name:TAYLOR COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED SUBSTANCE ABUSE COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:CADC III, IDP-AT
Authorized Official - Phone:715-748-3332
Mailing Address - Street 1:540 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-2027
Mailing Address - Country:US
Mailing Address - Phone:715-748-3332
Mailing Address - Fax:715-748-3342
Practice Address - Street 1:540 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-2027
Practice Address - Country:US
Practice Address - Phone:715-748-3332
Practice Address - Fax:715-748-3342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11414101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI72970OtherSECURITY HEALTH PLAN INS
WI11414OtherSTATE LICENSE NUMBER
WI39385400Medicaid