Provider Demographics
NPI:1629114780
Name:ANDERSON, JONATHAN F (MA, LPC-S, LCMHC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:F
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MA, LPC-S, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3939 BEE CAVES RD STE A203
Mailing Address - Street 2:
Mailing Address - City:WEST LAKE HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:78746-6429
Mailing Address - Country:US
Mailing Address - Phone:512-771-7621
Mailing Address - Fax:
Practice Address - Street 1:3939 BEE CAVES RD STE A203
Practice Address - Street 2:
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-6429
Practice Address - Country:US
Practice Address - Phone:512-771-7621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT044204174400000X
TX16807101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150911901Medicaid