Provider Demographics
NPI:1477609212
Name:RICHESON, JONATHAN SCOTT (BS)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:SCOTT
Last Name:RICHESON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:SAINT DAVID
Mailing Address - State:AZ
Mailing Address - Zip Code:85630-0334
Mailing Address - Country:US
Mailing Address - Phone:520-720-8606
Mailing Address - Fax:
Practice Address - Street 1:440 N MARK ST
Practice Address - Street 2:
Practice Address - City:SAINT DAVID
Practice Address - State:AZ
Practice Address - Zip Code:85630-0334
Practice Address - Country:US
Practice Address - Phone:520-720-8606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL4128235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist