Provider Demographics
NPI:1639258981
Name:WITT, JASON A (MA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:A
Last Name:WITT
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 TENNY AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-6450
Mailing Address - Country:US
Mailing Address - Phone:262-501-2975
Mailing Address - Fax:414-321-0552
Practice Address - Street 1:4402 S 68TH ST
Practice Address - Street 2:#100
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-3479
Practice Address - Country:US
Practice Address - Phone:414-321-4411
Practice Address - Fax:414-321-0552
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40924900Medicaid