Healthcare Provider Details

I. General information

NPI: 1689366387
Provider Name (Legal Business Name): JONATHAN MORALES VALADEZ PCTL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6025 N GREEN BAY AVE STE 2
MILWAUKEE WI
53209-3750
US

IV. Provider business mailing address

2363 S 102ND ST STE 303
WEST ALLIS WI
53227-2115
US

V. Phone/Fax

Practice location:
  • Phone: 414-247-0801
  • Fax:
Mailing address:
  • Phone: 414-204-5174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7339-226
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12154-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: