Provider Demographics
NPI:1982734372
Name:COHEN, JONATHAN M (LAC, AP)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:M
Last Name:COHEN
Suffix:
Gender:M
Credentials:LAC, AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 LINDA AVE
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-7245
Mailing Address - Country:US
Mailing Address - Phone:386-947-9009
Mailing Address - Fax:
Practice Address - Street 1:721 RIDGEWOOD AVE.
Practice Address - Street 2:STE. 9
Practice Address - City:HOLLY HILL,
Practice Address - State:FL
Practice Address - Zip Code:32117
Practice Address - Country:US
Practice Address - Phone:386-947-9009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP1615171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000749494OtherAETNA PIN
FLCO777OtherBCBS PROVIDER #