Provider Demographics
NPI:1689090979
Name:FOURTHMAN, JOHNATHAN ERIC
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:ERIC
Last Name:FOURTHMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E JACKSON ST
Mailing Address - Street 2:STE 2340
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5233
Mailing Address - Country:US
Mailing Address - Phone:813-841-5032
Mailing Address - Fax:
Practice Address - Street 1:401 E JACKSON ST
Practice Address - Street 2:STE 2340
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-5233
Practice Address - Country:US
Practice Address - Phone:813-841-5032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid