MEDICARE: DR. JONATHAN MATTHEW BLAIR PH.D.

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	103TC0700X	Clinical Psychologist	6301014658	MI
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1285940064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN MATTHEW BLAIR PH.D.

Provider Business Mailing Address
First Line	:	5123 W ST JOE HWY
Second Line	:	SUITE 103
City	:	LANSING
State	:	MI
Zip	:	48917-4093
Country	:	US
Telephone Number	:	517-323-4099
Fax Number	:	517-323-3334

Provider Business Practice Location Address
First Line	:	5123 W ST JOE HWY
Second Line	:	SUITE 103
City	:	LANSING
State	:	MI
Zip	:	48917-4093
Country	:	US
Telephone Number	:	517-323-4099
Fax Number	:	517-323-3334

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

Provider Enumeration Date	:	08/31/2010
Last Update Date	:	12/28/2011

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