Provider Demographics
NPI:1972081347
Name:ANDERSON, JONAH MICAL (LPC, MA, CSAT)
Entity type:Individual
Prefix:
First Name:JONAH
Middle Name:MICAL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LPC, MA, CSAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11632 W BLUEMOUND RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3937
Mailing Address - Country:US
Mailing Address - Phone:262-302-0016
Mailing Address - Fax:608-509-7310
Practice Address - Street 1:300 COTTONWOOD AVE STE 8
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-2043
Practice Address - Country:US
Practice Address - Phone:262-302-0016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-29
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI559767101YM0800X, 101YA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)