Provider Demographics
NPI:1336725720
Name:JARVIS, AUTUMN MARIE (LICSW)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:MARIE
Last Name:JARVIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:MARIE
Other - Last Name:ERDMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1580 S HURON RD APT 4
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8075
Mailing Address - Country:US
Mailing Address - Phone:715-410-3433
Mailing Address - Fax:
Practice Address - Street 1:502 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1913
Practice Address - Country:US
Practice Address - Phone:218-786-8376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13129-121104100000X
WI98231041C0700X
MN314861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI9823OtherLICENSE