Provider Demographics
NPI:1023561917
Name:STOCKFORD, JONATHAN (ED M, MA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:STOCKFORD
Suffix:
Gender:M
Credentials:ED M, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356 SAINT JOHNS PL
Mailing Address - Street 2:APARTMENT 1D
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-5343
Mailing Address - Country:US
Mailing Address - Phone:917-324-4917
Mailing Address - Fax:
Practice Address - Street 1:356 SAINT JOHNS PL
Practice Address - Street 2:APARTMENT 1D
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-5343
Practice Address - Country:US
Practice Address - Phone:917-324-4917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool