Provider Demographics
NPI:1922071083
Name:DOUGLAS, JON C (AUD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:C
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 HIGHLAND AVE
Mailing Address - Street 2:WAISMAN CENTER
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-2274
Mailing Address - Country:US
Mailing Address - Phone:608-263-5804
Mailing Address - Fax:
Practice Address - Street 1:1975 WILLOW DR
Practice Address - Street 2:UNIVERSITY OF WISCONSIN SPEECH AND HEARING CLINIC
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53706-1103
Practice Address - Country:US
Practice Address - Phone:608-263-5804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI500-156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41153000Medicaid
WI60633OtherDEAN HEALTH INSURANCE
WI74150036AMedicare ID - Type Unspecified
WIP00379510Medicare ID - Type UnspecifiedRAILROAD MEDICARE
WI41153000Medicaid