Provider Demographics
NPI:1154764827
Name:JONATHAN M. BLAIR PHD, PLLC
Entity type:Organization
Organization Name:JONATHAN M. BLAIR PHD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:774-239-8605
Mailing Address - Street 1:2909 S CAMBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-1024
Mailing Address - Country:US
Mailing Address - Phone:774-239-8605
Mailing Address - Fax:
Practice Address - Street 1:5123 W ST JOE HWY
Practice Address - Street 2:SUITE 103
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-4093
Practice Address - Country:US
Practice Address - Phone:517-323-4099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014658103T00000X, 103TC0700X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty