Provider Demographics
NPI:1306140967
Name:LICHMAN, JACOB J JR (CSAC IDP/AT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:J
Last Name:LICHMAN
Suffix:JR
Gender:M
Credentials:CSAC IDP/AT
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:J
Other - Last Name:LICHMAN
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:CSAC IDP/AT
Mailing Address - Street 1:PO BOX 57
Mailing Address - Street 2:
Mailing Address - City:MONTELLO
Mailing Address - State:WI
Mailing Address - Zip Code:53949-0057
Mailing Address - Country:US
Mailing Address - Phone:608-297-2085
Mailing Address - Fax:608-297-2426
Practice Address - Street 1:N3829 STATE ROAD 22
Practice Address - Street 2:
Practice Address - City:MONTELLO
Practice Address - State:WI
Practice Address - Zip Code:53949-9049
Practice Address - Country:US
Practice Address - Phone:608-297-2085
Practice Address - Fax:608-297-2426
Is Sole Proprietor?:No
Enumeration Date:2010-12-22
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1853-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)