Healthcare Provider Details

I. General information

NPI: 1154764827
Provider Name (Legal Business Name): JONATHAN M. BLAIR PHD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2013
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5123 W ST JOE HWY SUITE 103
LANSING MI
48917-4093
US

IV. Provider business mailing address

2909 S CAMBRIDGE RD
LANSING MI
48911-1024
US

V. Phone/Fax

Practice location:
  • Phone: 517-323-4099
  • Fax:
Mailing address:
  • Phone: 774-239-8605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301014658
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301014658
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number6301014658
License Number StateMI

VIII. Authorized Official

Name: DR. JONATHAN MATTHEW BLAIR
Title or Position: LICENSED PSYCHOLOGIST
Credential: PHD
Phone: 774-239-8605