Healthcare Provider Details

I. General information

NPI: 1306793443
Provider Name (Legal Business Name): JONATHAN MEDINE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2026
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 NORTH ST
DENHAM SPRINGS LA
70726-4347
US

IV. Provider business mailing address

30665 WALKER RD N
WALKER LA
70785-5602
US

V. Phone/Fax

Practice location:
  • Phone: 225-243-5363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPLC10371
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: