Healthcare Provider Details

I. General information

NPI: 1093059859
Provider Name (Legal Business Name): JONATHAN DAVID DOUGLASS MA, LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2012
Last Update Date: 11/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 ZION RD STE 209
NORTHFIELD NJ
08225-1844
US

IV. Provider business mailing address

1750 ZION RD STE 209
NORTHFIELD NJ
08225-1844
US

V. Phone/Fax

Practice location:
  • Phone: 609-204-6134
  • Fax: 570-864-3353
Mailing address:
  • Phone: 609-204-6134
  • Fax: 570-864-3353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37AC00141100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37AC00141100
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number37AC00141100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: