Provider Demographics
NPI:1386988293
Name:RICHARDSON, JEFFREY D (CSAC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-6511
Mailing Address - Country:US
Mailing Address - Phone:262-345-5560
Mailing Address - Fax:262-345-5531
Practice Address - Street 1:757 S MAIN ST
Practice Address - Street 2:SUITE 8
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-5739
Practice Address - Country:US
Practice Address - Phone:920-731-9798
Practice Address - Fax:920-731-1097
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15702-132101YA0400X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor