Provider Demographics
NPI:1275923484
Name:MURDAUGH, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MURDAUGH
Suffix:
Gender:M
Credentials:
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 1332
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:SC
Mailing Address - Zip Code:29827-1332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1040 TINKER TOWN RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:SC
Practice Address - Zip Code:29827-7220
Practice Address - Country:US
Practice Address - Phone:803-686-0412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-26
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation