Provider Demographics
NPI:1104965318
Name:PSENKA, JONATHAN (NMD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:PSENKA
Suffix:
Gender:M
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8611 N BLACK CANYON HWY
Mailing Address - Street 2:SUITE 214
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-4105
Mailing Address - Country:US
Mailing Address - Phone:602-358-7429
Mailing Address - Fax:602-358-7434
Practice Address - Street 1:13832 N 32ND ST
Practice Address - Street 2:SUITE 126
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-5613
Practice Address - Country:US
Practice Address - Phone:602-493-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ03-772175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0944610Medicare UPIN