MEDICARE: JONATHAN CORDELL PSYD

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	103T00000X	Psychologist	6654	NC
2	103T00000X	Psychologist	35SI00700000	NJ
3	103T00000X	Psychologist	2249	AL

General Provider Information

NPI Number	:	1689394116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN CORDELL PSYD

Provider Business Mailing Address
First Line	:	2005 BIG PANTHER DR
Second Line	:
City	:	WILLOW SPRING
State	:	NC
Zip	:	27592-6020
Country	:	US
Telephone Number	:	919-816-5820
Fax Number	:

Provider Business Practice Location Address
First Line	:	2005 BIG PANTHER DR
Second Line	:
City	:	WILLOW SPRING
State	:	NC
Zip	:	27592-6020
Country	:	US
Telephone Number	:	919-816-5820
Fax Number	:

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

Provider Enumeration Date	:	09/02/2022
Last Update Date	:	11/10/2024

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