Healthcare Provider Details

I. General information

NPI: 1104600824
Provider Name (Legal Business Name): JONATHAN WILLIAM MARIN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2023
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1095 MIDWAY RD
MENASHA WI
54952-1115
US

IV. Provider business mailing address

1095 MIDWAY RD
MENASHA WI
54952-1115
US

V. Phone/Fax

Practice location:
  • Phone: 920-720-2300
  • Fax: 920-720-3719
Mailing address:
  • Phone: 920-720-2300
  • Fax: 920-720-3719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3062-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: