Provider Demographics
NPI:1003092479
Name:JONATHAN D CARGILL, PHD, INC
Entity Type:Organization
Organization Name:JONATHAN D CARGILL, PHD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:CARGILL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:405-598-3668
Mailing Address - Street 1:PO BOX 114
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:OK
Mailing Address - Zip Code:74873-0114
Mailing Address - Country:US
Mailing Address - Phone:405-598-3668
Mailing Address - Fax:405-598-0338
Practice Address - Street 1:23 E 9TH ST
Practice Address - Street 2:SUITE 311
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-6943
Practice Address - Country:US
Practice Address - Phone:405-275-6701
Practice Address - Fax:405-598-3668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK300103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty