Provider Demographics
NPI:1396101838
Name:LUCKENBAUGH, JON
Entity type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:LUCKENBAUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3921 E FOURTH PLAIN BLVD UNIT 12
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-5797
Mailing Address - Country:US
Mailing Address - Phone:360-773-2309
Mailing Address - Fax:
Practice Address - Street 1:7415 NE 94TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-3859
Practice Address - Country:US
Practice Address - Phone:360-253-6019
Practice Address - Fax:360-253-2698
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60517550101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor