Provider Demographics
NPI:1053773150
Name:ENTIS, JONATHAN JOSHUA (PHD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:JOSHUA
Last Name:ENTIS
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 1:240 CONCORD AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-1337
Mailing Address - Country:US
Mailing Address - Phone:617-702-2733
Mailing Address - Fax:
Practice Address - Street 1:240 CONCORD AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138
Practice Address - Country:US
Practice Address - Phone:617-702-2733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10695103TP2701X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy