Provider Demographics
NPI:1962967315
Name:BASTEN, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:BASTEN
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 1:1155 N ELM ST STE 120
Mailing Address - Street 2:
Mailing Address - City:PLATTEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53818-1207
Mailing Address - Country:US
Mailing Address - Phone:608-348-4060
Mailing Address - Fax:
Practice Address - Street 1:1155 N ELM ST STE 120
Practice Address - Street 2:
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-1207
Practice Address - Country:US
Practice Address - Phone:608-348-4060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health