Healthcare Provider Details

I. General information

NPI: 1740802941
Provider Name (Legal Business Name): JOHNATHAN JAY MARCHBANKS MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 EAGLE CTR
O FALLON IL
62269-1945
US

IV. Provider business mailing address

7 FOURSCORE DR
BELLEVILLE IL
62226-4807
US

V. Phone/Fax

Practice location:
  • Phone: 618-206-8816
  • Fax:
Mailing address:
  • Phone: 618-744-4015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateMO
# 6
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: