Provider Demographics
NPI:1316141278
Name:LIBSTER, JACOB M (BSW)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:M
Last Name:LIBSTER
Suffix:
Gender:M
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:848 STATE ROAD 60
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-9216
Mailing Address - Country:US
Mailing Address - Phone:262-375-6794
Mailing Address - Fax:
Practice Address - Street 1:5407 8TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-3715
Practice Address - Country:US
Practice Address - Phone:262-564-0067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health