Provider Demographics
NPI:1013469063
Name:TODD, JONATHAN (LPC-INTERN)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:TODD
Suffix:
Gender:M
Credentials:LPC-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 E GREENBRIAR LN
Mailing Address - Street 2:APT. 1214
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75203-1078
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4054 MCKINNEY AVE
Practice Address - Street 2:102
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-8212
Practice Address - Country:US
Practice Address - Phone:214-520-6308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX76679101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional