Provider Demographics
NPI:1548498298
Name:KOHLENBERG, JARED M (DO)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:M
Last Name:KOHLENBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 COUNTY ROAD A
Mailing Address - Street 2:
Mailing Address - City:GREEN LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54941-8608
Mailing Address - Country:US
Mailing Address - Phone:920-294-0100
Mailing Address - Fax:920-294-0123
Practice Address - Street 1:670 COUNTY ROAD A
Practice Address - Street 2:
Practice Address - City:GREEN LAKE
Practice Address - State:WI
Practice Address - Zip Code:54941-8608
Practice Address - Country:US
Practice Address - Phone:920-294-0100
Practice Address - Fax:920-294-0123
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI57315-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1548498298Medicaid
WI1548498298Medicaid