Provider Demographics
NPI:1669573770
Name:COLE, JONATHAN D (PHD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:D
Last Name:COLE
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:BLUEGRASS HEALTH PSYCHOLOGY, INC.
Mailing Address - Street 2:4101 TATES CREEK CTR DR STE 150, PMB 123
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-3066
Mailing Address - Country:US
Mailing Address - Phone:859-277-1008
Mailing Address - Fax:859-277-1083
Practice Address - Street 1:BLUEGRASS HEALTH PSYCHOLOGY, INC.
Practice Address - Street 2:2220 YOUNG DRIVE
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505-4219
Practice Address - Country:US
Practice Address - Phone:859-277-1008
Practice Address - Fax:859-277-1083
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1200103TH0004X, 103TH0100X, 103TC0700X
KY128960103TH0004X, 103TH0100X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY89000749Medicaid
MS388759ZL7WMedicare PIN
KY89000749Medicaid
KY00215Medicare PIN