Provider Demographics
NPI:1447511183
Name:RICHTER, JACKIE K (CSAC)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:K
Last Name:RICHTER
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:K
Other - Last Name:RICHTER-MOSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SAC
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1510
Mailing Address - Country:US
Mailing Address - Phone:715-838-3635
Mailing Address - Fax:
Practice Address - Street 1:212 11TH ST S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4116
Practice Address - Country:US
Practice Address - Phone:608-392-9555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15750101YA0400X
WI5179101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional