Provider Demographics
NPI:1861241317
Name:WHEELER, JACK O
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:O
Last Name:WHEELER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8010
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53547-8010
Mailing Address - Country:US
Mailing Address - Phone:608-757-0404
Mailing Address - Fax:608-757-2319
Practice Address - Street 1:1 S MAIN ST STE 250
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-3939
Practice Address - Country:US
Practice Address - Phone:608-757-0404
Practice Address - Fax:608-757-2319
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7849-226101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor