Provider Demographics
NPI:1093059859
Name:DOUGLASS, JONATHAN DAVID (MA, LAC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DAVID
Last Name:DOUGLASS
Suffix:
Gender:M
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 ZION RD STE 209
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08225-1844
Mailing Address - Country:US
Mailing Address - Phone:609-204-6134
Mailing Address - Fax:570-864-3353
Practice Address - Street 1:1750 ZION RD STE 209
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08225-1844
Practice Address - Country:US
Practice Address - Phone:609-204-6134
Practice Address - Fax:570-864-3353
Is Sole Proprietor?:No
Enumeration Date:2012-11-18
Last Update Date:2012-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00141100101YA0400X, 101YP2500X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist