Provider Demographics
NPI:1891163804
Name:PROCTER, JONATHAN (PHD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:PROCTER
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 1:100 N VILLAGE AVE STE 18
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-3712
Mailing Address - Country:US
Mailing Address - Phone:917-520-9366
Mailing Address - Fax:
Practice Address - Street 1:100 N VILLAGE AVE STE 18
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3712
Practice Address - Country:US
Practice Address - Phone:917-520-9366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74384101YP2500X
NY007837103TC1900X, 103TC2200X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent