Healthcare Provider Details

I. General information

NPI: 1326347311
Provider Name (Legal Business Name): JONATHAN LYNN HARTSELL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2011
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 BOONE STREET SUITE 27
JOHNSON CITY TN
37604
US

IV. Provider business mailing address

2101 CHEROKEE RD UNIT 4
JOHNSON CITY TN
37604-3474
US

V. Phone/Fax

Practice location:
  • Phone: 423-444-3677
  • Fax:
Mailing address:
  • Phone: 423-426-4733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5391
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: