Provider Demographics
NPI:1972571776
Name:NEUFELD, JONATHAN DALE (PHD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DALE
Last Name:NEUFELD
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:PO BOX 809
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46527-0809
Mailing Address - Country:US
Mailing Address - Phone:574-533-1234
Mailing Address - Fax:574-537-2652
Practice Address - Street 1:330 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-9365
Practice Address - Country:US
Practice Address - Phone:574-533-1234
Practice Address - Fax:574-537-2652
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17420103TC0700X
IN20042056A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200888680Medicaid
IN200804500AMedicaid
CA234780Medicare PIN
IN200804500AMedicaid
CAP34886Medicare UPIN
IN247490AMedicare PIN