Provider Demographics
NPI:1659480333
Name:SIMONS, JONATHAN ALAN (PHD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ALAN
Last Name:SIMONS
Suffix:
Gender:M
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 859
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585
Mailing Address - Country:US
Mailing Address - Phone:843-828-0502
Mailing Address - Fax:843-828-4402
Practice Address - Street 1:1506 AZALEA DRIVE
Practice Address - Street 2:SUITE 602
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575
Practice Address - Country:US
Practice Address - Phone:843-828-0502
Practice Address - Fax:843-828-4402
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC639103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0245Medicaid
SCQ313770283Medicare ID - Type Unspecified