Provider Demographics
NPI:1356549224
Name:DETWILER, JON DOUGLAS (MA)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:DOUGLAS
Last Name:DETWILER
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 1:1801 E 5TH ST
Mailing Address - Street 2:STE. 212
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2379
Mailing Address - Country:US
Mailing Address - Phone:704-358-3025
Mailing Address - Fax:
Practice Address - Street 1:1801 E 5TH ST
Practice Address - Street 2:STE. 212
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2379
Practice Address - Country:US
Practice Address - Phone:704-358-3025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC863106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist