Provider Demographics
NPI:1841516424
Name:IRISH, JONATHAN KYLE (MA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:KYLE
Last Name:IRISH
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:N8093 LAKEVIEW RD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-5517
Mailing Address - Country:US
Mailing Address - Phone:619-865-2113
Mailing Address - Fax:
Practice Address - Street 1:2574 SUN VALLEY DR STE 207
Practice Address - Street 2:
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018-2334
Practice Address - Country:US
Practice Address - Phone:619-865-2113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-08
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6441-125101YP2500X, 101Y00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty