| Doctor Name: | MR. JACK GEORGE RUDOLPH |
| NPI Number: | 1487823308 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | 2651-125 |
| Business Practice Address: | 540 College Ave Medford, WI - 544512027 |
| Business Phone Number: | 7157483332 |
| Business Fax Number: | 7157483342 |
| Mailing Address: | 540 College Ave, MEDFORD |
| State: | WI |
| Postal Code: | 544512027 |
| Phone Number: | 7157483332 |
| Fax Number: | 7157483342 |
| NPI Enumeration Date: | 02/25/2008 |
| NPI Last Update Date: | 03/13/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101Y00000X |
| License Number: | 2651-125 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A provider who is trained and educated in the performance of behavior health services through interpersonal communications and analysis. Training and education at the specialty level usually requires a master |