Provider Demographics
NPI:1356815872
Name:WARD, JONATHAN MICHAEL (BSP, MBA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:WARD
Suffix:
Gender:M
Credentials:BSP, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 29
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-0029
Mailing Address - Country:US
Mailing Address - Phone:608-355-4289
Mailing Address - Fax:
Practice Address - Street 1:505 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-2183
Practice Address - Country:US
Practice Address - Phone:608-355-4289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI123456101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor