Provider Demographics
NPI:1063909307
Name:THOMAS, JONATHON
Entity type:Individual
Prefix:
First Name:JONATHON
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16255 VENTURA BLVD STE 830
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2317
Mailing Address - Country:US
Mailing Address - Phone:801-710-7888
Mailing Address - Fax:
Practice Address - Street 1:770 PARK CENTRE DR
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-3598
Practice Address - Country:US
Practice Address - Phone:704-780-4271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106S00000X
106S00000X
UTRBT-18-52417106S00000X
UT11997268-2506103K00000X
UT11997268-2507106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTW222530056OtherATENA