Provider Demographics
NPI:1215219019
Name:MUCKELROY, JONNIE M
Entity type:Individual
Prefix:
First Name:JONNIE
Middle Name:M
Last Name:MUCKELROY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37951 47TH ST E # A7-221
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93552-3264
Mailing Address - Country:US
Mailing Address - Phone:661-941-1131
Mailing Address - Fax:
Practice Address - Street 1:190 SIERRA CT STE C4
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-7609
Practice Address - Country:US
Practice Address - Phone:661-941-1131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2025-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT116647106H00000X
CAIMF84193106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL