Provider Demographics
NPI:1154091932
Name:RUTHERFORD, JONATHAN HOWELL (PMHNP)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:HOWELL
Last Name:RUTHERFORD
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 N F AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-1920
Mailing Address - Country:US
Mailing Address - Phone:520-364-6852
Mailing Address - Fax:520-364-4261
Practice Address - Street 1:155 CALLE PORTAL STE 300
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2900
Practice Address - Country:US
Practice Address - Phone:520-459-3011
Practice Address - Fax:520-364-4261
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ260129363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ106788Medicaid