Provider Demographics
NPI:1780207936
Name:SMITH, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:SMITH
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 1:1801 WATERMARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-7088
Mailing Address - Country:US
Mailing Address - Phone:614-487-8758
Mailing Address - Fax:614-227-9447
Practice Address - Street 1:11156 CANAL RD STE A
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45241-5816
Practice Address - Country:US
Practice Address - Phone:614-487-8758
Practice Address - Fax:614-227-9447
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-22
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 251S00000X
OH172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health