Basic Information
| Provider Information | |||||||||
| NPI: | 1154764827 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JONATHAN M. BLAIR PHD, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2909 S CAMBRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489111024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7742398605 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5123 W ST JOE HWY | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489174093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173234099 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2013 | ||||||||
| LastUpdateDate: | 04/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | BLAIR | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | MATTHEW | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSED PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 7742398605 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301014658 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TF0000X | 6301014658 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Family | 103T00000X | 6301014658 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.