1487610614 NPI number — JODY L KLUMB LCSW

Table of content: JODY L KLUMB LCSW (NPI 1487610614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487610614 NPI number — JODY L KLUMB LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLUMB
Provider First Name:
JODY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487610614
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 TOWER DR
Provider Second Line Business Mailing Address:
DEAN MEDICAL CENTER
Provider Business Mailing Address City Name:
SUN PRAIRIE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53590-1239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-825-3008
Provider Business Mailing Address Fax Number:
608-825-3793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 TOWER DR
Provider Second Line Business Practice Location Address:
DEAN MEDICAL CENTER
Provider Business Practice Location Address City Name:
SUN PRAIRIE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53590-1239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-825-3008
Provider Business Practice Location Address Fax Number:
608-825-3793
Provider Enumeration Date:
04/25/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  621-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 39275300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7981 . This is a "DEAN HEALTH INSURANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".