Provider Demographics
NPI:1558588806
Name:ATHEARN, JONATHAN (TLLP)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:ATHEARN
Suffix:
Gender:M
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4229 HOMESTEAD
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49348-8975
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1331 LAKE DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1674
Practice Address - Country:US
Practice Address - Phone:616-459-7215
Practice Address - Fax:616-235-0979
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013388103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling