Provider Demographics
NPI:1649309337
Name:NATHAN, JONATHAN JOEL (MSW LICSW)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:JOEL
Last Name:NATHAN
Suffix:
Gender:M
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:330 MOUNT AUBURN STREET
Mailing Address - Street 2:MOUNT AUBURN HOSPITAL OUTPATIENT PSYCHIATRY DEPARTMENT
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138
Mailing Address - Country:US
Mailing Address - Phone:617-499-5665
Mailing Address - Fax:
Practice Address - Street 1:330 MOUNT AUBURN ST
Practice Address - Street 2:MOUNT AUBURN HOSPITAL OUTPATIENT PSYCHIATRY DEPT
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5502
Practice Address - Country:US
Practice Address - Phone:617-499-5665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10322661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP21819Medicare ID - Type Unspecified