Provider Demographics
NPI:1699383547
Name:TYLER, JONATHAN GREGORY (LICSW)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:GREGORY
Last Name:TYLER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4909 MADISON CIR
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35475-4468
Mailing Address - Country:US
Mailing Address - Phone:205-454-4479
Mailing Address - Fax:
Practice Address - Street 1:420 28TH AVE
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-1088
Practice Address - Country:US
Practice Address - Phone:205-737-3720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3578G101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor