Provider Demographics
NPI:1275244550
Name:GATES, JONATHAN RYAN (MC, LPC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:RYAN
Last Name:GATES
Suffix:
Gender:M
Credentials:MC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7254 E SOUTHERN AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-2787
Mailing Address - Country:US
Mailing Address - Phone:505-270-6677
Mailing Address - Fax:
Practice Address - Street 1:7254 E SOUTHERN AVE STE 106
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-2787
Practice Address - Country:US
Practice Address - Phone:505-270-6677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-21545101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional