Provider Demographics
NPI:1336945153
Name:KALLAS, JASON R (LPC-IT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:KALLAS
Suffix:
Gender:
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3278 COUNTY RD E
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:WI
Mailing Address - Zip Code:54963-9635
Mailing Address - Country:US
Mailing Address - Phone:920-509-8987
Mailing Address - Fax:
Practice Address - Street 1:3278 COUNTY RD E
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:WI
Practice Address - Zip Code:54963-9635
Practice Address - Country:US
Practice Address - Phone:920-509-8987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8330-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health