Provider Demographics
NPI:1104684646
Name:MANGANO, JONATHAN MICHAEL (LMFT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:MANGANO
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8635 N CRESTVIEW TRL
Mailing Address - Street 2:
Mailing Address - City:MCCORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46055-6206
Mailing Address - Country:US
Mailing Address - Phone:217-671-7058
Mailing Address - Fax:
Practice Address - Street 1:13578 E 131ST ST STE 260
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-6401
Practice Address - Country:US
Practice Address - Phone:317-827-7870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35002315A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist