Provider Demographics
NPI:1679754055
Name:GORHAM, JONATHAN PAUL (PSYD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:PAUL
Last Name:GORHAM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:697 LOUISIANA DR.
Mailing Address - Street 2:
Mailing Address - City:DYESS AFB
Mailing Address - State:TX
Mailing Address - Zip Code:79607
Mailing Address - Country:US
Mailing Address - Phone:325-696-5380
Mailing Address - Fax:352-696-5579
Practice Address - Street 1:697 LOUISIANA DR.
Practice Address - Street 2:
Practice Address - City:DYESS AFB
Practice Address - State:TX
Practice Address - Zip Code:79607
Practice Address - Country:US
Practice Address - Phone:325-696-5380
Practice Address - Fax:352-696-5579
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019063-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical