Provider Demographics
NPI:1275746190
Name:COHEN, JONATHAN D (PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:D
Last Name:COHEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:394 SW STORY PLACE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024
Mailing Address - Country:US
Mailing Address - Phone:386-288-4734
Mailing Address - Fax:
Practice Address - Street 1:1188 SW MAIN BLVD STE 1
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-6684
Practice Address - Country:US
Practice Address - Phone:386-288-4734
Practice Address - Fax:866-472-1489
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6711103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAI172OtherMEDICARE PTAN