Provider Demographics
NPI:1487454435
Name:DAVID, JONATHAN (LLPC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:DAVID
Suffix:
Gender:M
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2580 FLINT CT BLDG 5
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-3613
Mailing Address - Country:US
Mailing Address - Phone:301-944-4591
Mailing Address - Fax:
Practice Address - Street 1:3408 NILES RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8628
Practice Address - Country:US
Practice Address - Phone:269-429-3324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013838101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health