Provider Demographics
NPI:1598572612
Name:DAMBACHER, JONATHAN MICAH (SUDP-T)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MICAH
Last Name:DAMBACHER
Suffix:
Gender:M
Credentials:SUDP-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 AUBURN WAY N
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-1805
Mailing Address - Country:US
Mailing Address - Phone:253-999-5731
Mailing Address - Fax:253-999-5740
Practice Address - Street 1:3320 AUBURN WAY N
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-1805
Practice Address - Country:US
Practice Address - Phone:253-999-5731
Practice Address - Fax:253-999-5740
Is Sole Proprietor?:No
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61632144101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)