Basic Information
| Provider Information | |||||||||
| NPI: | 1396019279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | SAC-IT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1709 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532011709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625107953 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2603 N MARTIN LUTHER KING DR | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532122711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142638352 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2012 | ||||||||
| LastUpdateDate: | 02/24/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 15567-130 | WI | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.