Provider Demographics
NPI:1891163804
Name:PROCTER, JONATHAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:PROCTER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 MLK BLVD
Mailing Address - Street 2:EDUCATION BUILDING 115
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77710
Mailing Address - Country:US
Mailing Address - Phone:409-880-7681
Mailing Address - Fax:
Practice Address - Street 1:4400 MLK BLVD
Practice Address - Street 2:EDUCATION BUILDING 115
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77710
Practice Address - Country:US
Practice Address - Phone:409-880-7681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74384101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional