Provider Demographics
NPI:1225702046
Name:RODIS, JONATHAN DAVID (LPC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DAVID
Last Name:RODIS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6768 E SAN CRISTOBAL WAY
Mailing Address - Street 2:
Mailing Address - City:GOLD CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:85118-1898
Mailing Address - Country:US
Mailing Address - Phone:602-361-6888
Mailing Address - Fax:
Practice Address - Street 1:6768 E SAN CRISTOBAL WAY
Practice Address - Street 2:
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85118-1898
Practice Address - Country:US
Practice Address - Phone:602-361-6888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-19286101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health