MEDICARE: DR. JONATHAN RAY SQUYRES PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	18907	TX
2	103T00000X	Psychologist	38103	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285629055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN RAY SQUYRES PHD

Provider Business Mailing Address
First Line	:	130 MICHAELS LOOP
Second Line	:
City	:	LUFKIN
State	:	TX
Zip	:	75901-8317
Country	:	US
Telephone Number	:	936-824-5011
Fax Number	:

Provider Business Practice Location Address
First Line	:	130 MICHAELS LOOP
Second Line	:
City	:	LUFKIN
State	:	TX
Zip	:	75901-8317
Country	:	US
Telephone Number	:	936-824-5011
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2005
Last Update Date	:	10/11/2019

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