Provider Demographics
NPI:1679620413
Name:KNISKERN, JONATHAN RAMSEY (PHD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:RAMSEY
Last Name:KNISKERN
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:PO BOX 312
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-0312
Mailing Address - Country:US
Mailing Address - Phone:906-226-6675
Mailing Address - Fax:
Practice Address - Street 1:102 W WASHINGTON ST
Practice Address - Street 2:SUITE 226
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4368
Practice Address - Country:US
Practice Address - Phone:906-228-4747
Practice Address - Fax:906-226-2044
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005953103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
68OE245110OtherBLUE CROSS BLUE SHIELD
MIOE24511Medicare ID - Type Unspecified
MIR67556Medicare UPIN