Provider Demographics
NPI:1588435721
Name:MANDICH, JONATHAN RAY
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:RAY
Last Name:MANDICH
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 1:117 NE CLARK AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-8112
Mailing Address - Country:US
Mailing Address - Phone:360-949-2746
Mailing Address - Fax:
Practice Address - Street 1:117 NE CLARK AVE APT 2
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-8112
Practice Address - Country:US
Practice Address - Phone:360-949-2746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician