Provider Demographics
NPI:1407359805
Name:TOLBERT, JONNARDA
Entity type:Individual
Prefix:
First Name:JONNARDA
Middle Name:
Last Name:TOLBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6555 MONDA AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-4692
Mailing Address - Country:US
Mailing Address - Phone:219-781-8791
Mailing Address - Fax:
Practice Address - Street 1:8670 BROADWAY B
Practice Address - Street 2:SUITE E
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7034
Practice Address - Country:US
Practice Address - Phone:219-781-8791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-12
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88000570A101Y00000X, 101YM0800X
IN39003879A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor