Provider Demographics
NPI:1407223787
Name:CARR, JONATHAN MARCELLAS
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:MARCELLAS
Last Name:CARR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOHNATHAN
Other - Middle Name:MARCELLAS
Other - Last Name:CARR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED, LPCC
Mailing Address - Street 1:336 LUCILLE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-8796
Mailing Address - Country:US
Mailing Address - Phone:859-619-0684
Mailing Address - Fax:
Practice Address - Street 1:336 LUCILLE DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-8796
Practice Address - Country:US
Practice Address - Phone:859-619-0684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-21
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLPCCCA00218618101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY725568Medicaid