Provider Demographics
NPI:1528353257
Name:DAVIS, JONATHAN DAVID (MA, LPC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DAVID
Last Name:DAVIS
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 1:1012 W ABRIENDO AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1128
Mailing Address - Country:US
Mailing Address - Phone:719-583-2007
Mailing Address - Fax:
Practice Address - Street 1:1304 CHINOOK LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1851
Practice Address - Country:US
Practice Address - Phone:719-545-2746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0012457101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional