Healthcare Provider Details

I. General information

NPI: 1134881196
Provider Name (Legal Business Name): JONATHON JAGOW LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 S 76TH ST
MILWAUKEE WI
53214-1599
US

IV. Provider business mailing address

1107 S 31ST ST
MILWAUKEE WI
53215-1544
US

V. Phone/Fax

Practice location:
  • Phone: 414-292-4242
  • Fax: 414-543-2538
Mailing address:
  • Phone: 414-520-4058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: