Provider Demographics
NPI:1891483590
Name:WALL, JONATHAN KEITH (MSW)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:KEITH
Last Name:WALL
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 DATE PALM DR
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-2802
Mailing Address - Country:US
Mailing Address - Phone:919-612-9840
Mailing Address - Fax:
Practice Address - Street 1:114 DATE PALM DR
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-2802
Practice Address - Country:US
Practice Address - Phone:919-612-9840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW12721101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty