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General NPI Number Information
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NPI Number | 1306793443
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Entity Type | Individual
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Provider Name | JONATHAN MEDINE
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Gender | Male
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Dates
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Enumeration Date | 03/16/2026
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Last Update Date | 03/16/2026
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Provider Practice Location Address
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Address Line | 215 NORTH ST
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City | DENHAM SPRINGS
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State | LA
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Zip | 70726-4347
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Country | US
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Telephone | 225-243-5363
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Fax |
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Provider Business Mailing Address
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Address Line | 30665 WALKER RD N
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City | WALKER
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State | LA
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Zip | 70785-5602
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | PLC10371
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License Number State | LA
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