Provider Demographics
NPI:1598899197
Name:MATTHEW, JON S (PHD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:S
Last Name:MATTHEW
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53964-9068
Mailing Address - Country:US
Mailing Address - Phone:608-296-2139
Mailing Address - Fax:608-296-1590
Practice Address - Street 1:161 SPRING ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:WI
Practice Address - Zip Code:53964-9068
Practice Address - Country:US
Practice Address - Phone:608-296-2139
Practice Address - Fax:608-296-1590
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI822-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39018800Medicaid