Provider Demographics
NPI:1649970773
Name:KAUP, JEREMY L (PMHNP)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:L
Last Name:KAUP
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 4TH ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1005
Mailing Address - Country:US
Mailing Address - Phone:262-206-0412
Mailing Address - Fax:262-419-3818
Practice Address - Street 1:3224 KENNSINGTON SQUARE RD
Practice Address - Street 2:
Practice Address - City:STURTEVANT
Practice Address - State:WI
Practice Address - Zip Code:53177-2821
Practice Address - Country:US
Practice Address - Phone:262-762-9284
Practice Address - Fax:262-419-3818
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13690-33363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner