Provider Demographics
NPI:1730465311
Name:MCCULLOCH, JONATHAN PETER (LLMSW)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:PETER
Last Name:MCCULLOCH
Suffix:
Gender:M
Credentials:LLMSW
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Mailing Address - Street 1:COLONIAL WOODS CHRISTIAN COUNSELING CENTER
Mailing Address - Street 2:1101 MILITARY STREET
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-5418
Mailing Address - Country:US
Mailing Address - Phone:810-984-5575
Mailing Address - Fax:810-984-6433
Practice Address - Street 1:COLONIAL WOODS CHRISTIAN COUNSELING CENTER
Practice Address - Street 2:1101 MILITARY STREET
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5418
Practice Address - Country:US
Practice Address - Phone:810-984-5575
Practice Address - Fax:810-984-6433
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2023-09-20
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Provider Licenses
StateLicense IDTaxonomies
3747P1801X
MI68511151991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant