Provider Demographics
NPI:1952614323
Name:LASSITER, JONATHAN MATHIAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MATHIAS
Last Name:LASSITER
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 1:4312 WOODMONT CIR
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2285
Mailing Address - Country:US
Mailing Address - Phone:347-498-3575
Mailing Address - Fax:
Practice Address - Street 1:1133 BROADWAY STE 510
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-8173
Practice Address - Country:US
Practice Address - Phone:347-498-3575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-14
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022738103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical