Provider Demographics
NPI:1649069816
Name:SELF, JONATHAN CONNOR
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:CONNOR
Last Name:SELF
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-1914
Mailing Address - Country:US
Mailing Address - Phone:630-770-8983
Mailing Address - Fax:
Practice Address - Street 1:640 2ND AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-1914
Practice Address - Country:US
Practice Address - Phone:630-770-8983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL899731101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty