Provider Demographics
NPI:1043645039
Name:WOODBURY, JONATHAN DANIEL (LCAS,LPCA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DANIEL
Last Name:WOODBURY
Suffix:
Gender:M
Credentials:LCAS,LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 S ELM EUGENE ST STE 2009
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-2200
Mailing Address - Country:US
Mailing Address - Phone:336-457-2748
Mailing Address - Fax:
Practice Address - Street 1:1451 S ELM EUGENE ST STE 2009
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406
Practice Address - Country:US
Practice Address - Phone:336-457-2748
Practice Address - Fax:336-464-2544
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-20411101YA0400X
NCLPCA-A13656101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)