Provider Demographics
NPI:1396019279
Name:HALL, JONATHAN (SAC-IT)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:HALL
Suffix:
Gender:M
Credentials:SAC-IT
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 1709
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-1709
Mailing Address - Country:US
Mailing Address - Phone:262-510-7953
Mailing Address - Fax:
Practice Address - Street 1:2603 N MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2711
Practice Address - Country:US
Practice Address - Phone:414-263-8352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15567-130101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor