Provider Demographics
NPI:1023475787
Name:TODD, JONATHAN (MA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:TODD
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SUMMER VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29651-5636
Mailing Address - Country:US
Mailing Address - Phone:864-230-1621
Mailing Address - Fax:
Practice Address - Street 1:751 E GEORGIA RD
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:SC
Practice Address - Zip Code:29388-8787
Practice Address - Country:US
Practice Address - Phone:864-476-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1-15-21288103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst