Healthcare Provider Details

I. General information

NPI: 1134601404
Provider Name (Legal Business Name): JONATHAN DWAYNE MUCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 S WORTHEN ST
WENATCHEE WA
98801-3081
US

IV. Provider business mailing address

145 S WORTHEN ST
WENATCHEE WA
98801-3081
US

V. Phone/Fax

Practice location:
  • Phone: 509-662-6761
  • Fax: 509-662-3182
Mailing address:
  • Phone: 509-662-6761
  • Fax: 509-662-3182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH61620917
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: