Provider Demographics
NPI:1528114709
Name:CLOUD, JONATHAN MOORE (LCSW)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:MOORE
Last Name:CLOUD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2206 SOMERS AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-3338
Mailing Address - Country:US
Mailing Address - Phone:336-585-0140
Mailing Address - Fax:919-603-5090
Practice Address - Street 1:120 ORANGE ST STE A
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-3249
Practice Address - Country:US
Practice Address - Phone:336-212-9048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC000512101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC23153OtherNC HEALTH CHOICE
NC6002795Medicaid