Provider Demographics
NPI:1285940064
Name:BLAIR, JONATHAN MATTHEW (PHD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MATTHEW
Last Name:BLAIR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5123 W ST JOE HWY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-4093
Mailing Address - Country:US
Mailing Address - Phone:517-323-4099
Mailing Address - Fax:517-323-3334
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:517-323-3334
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014658103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program