Provider Demographics
NPI:1164514840
Name:RICHARDSON, JONATHAN HUGH THOMAS (PSYD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:HUGH THOMAS
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 778912
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8912
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:
Practice Address - Street 1:6640 INTECH BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-2011
Practice Address - Country:US
Practice Address - Phone:317-274-8812
Practice Address - Fax:317-274-0133
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2024-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042189103TC0700X
IN99023416A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN210870HMedicare PIN