Provider Demographics
NPI:1336961838
Name:MONDRAGON, JOHNATHAN VARGAS (SUDPT)
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:VARGAS
Last Name:MONDRAGON
Suffix:
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 MONITOR ST
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-3534
Mailing Address - Country:US
Mailing Address - Phone:509-232-5766
Mailing Address - Fax:
Practice Address - Street 1:1230 MONITOR ST
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-3534
Practice Address - Country:US
Practice Address - Phone:509-232-5766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61596664101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)