Provider Demographics
NPI:1760618417
Name:BAXTER, JONATHAN R (MA, MS, LMHC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:R
Last Name:BAXTER
Suffix:
Gender:M
Credentials:MA, MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1620 MASSACHUSETTS AVE STE 10
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-3826
Mailing Address - Country:US
Mailing Address - Phone:617-306-0264
Mailing Address - Fax:781-860-7200
Practice Address - Street 1:1620 MASSACHUSETTS AVE STE 10
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-3826
Practice Address - Country:US
Practice Address - Phone:617-306-0264
Practice Address - Fax:781-860-7200
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7969101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health