Healthcare Provider Details

I. General information

NPI: 1265006431
Provider Name (Legal Business Name): JONATHAN DAVID JOHNSTON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6380 LBJ FWY STE 299
DALLAS TX
75240-6439
US

IV. Provider business mailing address

3850 W NORTHWEST HWY APT 3408
DALLAS TX
75220-5230
US

V. Phone/Fax

Practice location:
  • Phone: 972-755-0996
  • Fax:
Mailing address:
  • Phone: 214-558-1216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number77708
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: