Provider Demographics
NPI:1902089691
Name:RICHARDSON, JONATHAN (PCC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15705 GREENDALE RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-3717
Mailing Address - Country:US
Mailing Address - Phone:216-587-3460
Mailing Address - Fax:
Practice Address - Street 1:15705 GREENDALE RD
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-3717
Practice Address - Country:US
Practice Address - Phone:216-587-3460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0500069101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health