| Doctor Name: | JACOB J LICHMAN |
| NPI Number: | 1306140967 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | CSAC IDP/AT |
| License Number: | 1853-132 |
| Business Practice Address: | N3829 State Road 22 Montello, WI - 539499049 |
| Business Phone Number: | 6082972085 |
| Business Fax Number: | 6082972426 |
| Mailing Address: | Po Box 57, MONTELLO |
| State: | WI |
| Postal Code: | 539490057 |
| Phone Number: | 6082972085 |
| Fax Number: | 6082972426 |
| NPI Enumeration Date: | 12/22/2010 |
| NPI Last Update Date: | 12/22/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 1853-132 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |