Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | 180007267 | IL |
NPI | 1003045337 |
---|---|
Provider Name | Mr. Jonathan Dean Ponser |
First Address | Springfield, IL 62702-6324 |
Second Address | Springfield, IL 62702-3759 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/07/2009 |
Last Update Date | 08/10/2013 |