Provider Demographics
NPI:1043508831
Name:JONATHAN, DOLLIE M
Entity Type:Individual
Prefix:
First Name:DOLLIE
Middle Name:M
Last Name:JONATHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 76069
Mailing Address - Street 2:
Mailing Address - City:TANACROSS
Mailing Address - State:AK
Mailing Address - Zip Code:99776-6069
Mailing Address - Country:US
Mailing Address - Phone:907-883-4472
Mailing Address - Fax:907-883-4472
Practice Address - Street 1:TANACROSS VILLAGE ROAD
Practice Address - Street 2:
Practice Address - City:TANACROSS
Practice Address - State:AK
Practice Address - Zip Code:99776-6069
Practice Address - Country:US
Practice Address - Phone:907-883-4472
Practice Address - Fax:907-883-4472
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)