Provider Demographics
NPI:1003413394
Name:BANNIGAN, JONATHAN CHARLES (MHC-LP)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:CHARLES
Last Name:BANNIGAN
Suffix:
Gender:M
Credentials:MHC-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 GLENWOOD AVE APT 2R
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2346
Mailing Address - Country:US
Mailing Address - Phone:315-335-0934
Mailing Address - Fax:
Practice Address - Street 1:260 MADISON AVE FL 8
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-2418
Practice Address - Country:US
Practice Address - Phone:212-335-0511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP107008101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health