Provider Demographics
NPI:1336157817
Name:BURCH, JONATHAN (MA, LPC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:BURCH
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 HITCHCOCK DR SW
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-5399
Mailing Address - Country:US
Mailing Address - Phone:803-514-2977
Mailing Address - Fax:
Practice Address - Street 1:3003 HIGHWAY 95 STE 104
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7802
Practice Address - Country:US
Practice Address - Phone:928-763-0250
Practice Address - Fax:928-763-0271
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-1903101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional