Healthcare Provider Details

I. General information

NPI: 1659973535
Provider Name (Legal Business Name): JONATHAN M MRNAK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2020
Last Update Date: 11/15/2020
Certification Date: 11/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2017 JEFFERSON ST SW
ROANOKE VA
24014-2419
US

IV. Provider business mailing address

2017 JEFFERSON ST SW
ROANOKE VA
24014-2419
US

V. Phone/Fax

Practice location:
  • Phone: 262-716-6309
  • Fax:
Mailing address:
  • Phone: 262-716-6309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904011159
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: