Provider Demographics
NPI:1285810390
Name:KILTY, JONAH J (DC)
Entity type:Individual
Prefix:
First Name:JONAH
Middle Name:J
Last Name:KILTY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-3958
Mailing Address - Country:US
Mailing Address - Phone:715-848-1741
Mailing Address - Fax:715-848-2225
Practice Address - Street 1:503 S CHERRY AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-4276
Practice Address - Country:US
Practice Address - Phone:715-389-1262
Practice Address - Fax:715-384-6992
Is Sole Proprietor?:No
Enumeration Date:2008-01-18
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4380-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38182800Medicaid
WI38182800Medicaid