Provider Demographics
NPI:1306195904
Name:PRYOR, JONATHAN WALLACE (MA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:WALLACE
Last Name:PRYOR
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N BROWN
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:TX
Mailing Address - Zip Code:76531-1518
Mailing Address - Country:US
Mailing Address - Phone:254-386-1800
Mailing Address - Fax:254-386-1826
Practice Address - Street 1:400 N BROWN
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:TX
Practice Address - Zip Code:76531-1518
Practice Address - Country:US
Practice Address - Phone:254-386-1800
Practice Address - Fax:254-386-1826
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66855101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional