Provider Demographics
NPI:1932784618
Name:LOUGH, JONATHAN R (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:R
Last Name:LOUGH
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 MONTROSE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-2627
Mailing Address - Country:US
Mailing Address - Phone:304-669-3271
Mailing Address - Fax:
Practice Address - Street 1:200 S RITCHIE AVE
Practice Address - Street 2:
Practice Address - City:RAVENSWOOD
Practice Address - State:WV
Practice Address - Zip Code:26164-1721
Practice Address - Country:US
Practice Address - Phone:304-273-9385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-14
Last Update Date:2021-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-1948235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist