Provider Demographics
NPI:1184813784
Name:MIDDLETONLOTTE, JONNIE MAE (PHD)
Entity type:Individual
Prefix:MS
First Name:JONNIE
Middle Name:MAE
Last Name:MIDDLETONLOTTE
Suffix:
Gender:F
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:PO BOX 841
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-0841
Mailing Address - Country:US
Mailing Address - Phone:417-770-3309
Mailing Address - Fax:417-771-5269
Practice Address - Street 1:1736 E SUNSHINE ST STE 510
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1331
Practice Address - Country:US
Practice Address - Phone:417-770-3309
Practice Address - Fax:417-771-5269
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007020570101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1184813784Medicaid