Healthcare Provider Details

I. General information

NPI: 1649776840
Provider Name (Legal Business Name): JONATHAN COUSAR RN,BSN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 04/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1668 HERLONG CT
ROCK HILL SC
29732-1193
US

IV. Provider business mailing address

1668 HERLONG CT
ROCK HILL SC
29732-1193
US

V. Phone/Fax

Practice location:
  • Phone: 803-323-6383
  • Fax: 803-328-2860
Mailing address:
  • Phone: 803-323-6383
  • Fax: 803-328-2860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number203834
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: