Provider Demographics
NPI:1871950022
Name:MEYER, JEAN BLAIR (LPC-IT)
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:BLAIR
Last Name:MEYER
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-1616
Mailing Address - Country:US
Mailing Address - Phone:920-296-7616
Mailing Address - Fax:
Practice Address - Street 1:115 N CENTER ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2119
Practice Address - Country:US
Practice Address - Phone:920-887-1766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2566226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health